Should insulin be given to a patient with hyperglycemia on hydrocortisone who is not a known diabetic?

Management of Hyperglycemia in Non-Diabetic Patient on Hydrocortisone

Yes, you should initiate glucose monitoring with correction insulin immediately, and if hyperglycemia persists (which is likely given the glucose of 200 mg/dL), proceed to scheduled insulin therapy, preferably NPH insulin given concomitantly with the hydrocortisone dose. 1, 2

Immediate Actions Required

Initiate Glucose Monitoring

• Start glucose monitoring with orders for correction insulin immediately for any patient receiving high-dose glucocorticoid therapy, even without known diabetes 1
• This patient already has documented hyperglycemia (200 mg/dL), confirming the need for intervention 1

Treatment Threshold Met

• This patient requires insulin therapy because the glucose of 200 mg/dL exceeds the recommended target of <180-200 mg/dL for non-critically ill hospitalized patients 1
• Patients with steroid-induced hyperglycemia should be treated to the same glycemic goals as patients with known diabetes 1

Insulin Regimen Selection

NPH Insulin is Preferred for Hydrocortisone-Induced Hyperglycemia

• NPH insulin is the standard approach for once- or twice-daily short-acting glucocorticoids like hydrocortisone 1, 2
• NPH should be administered concomitantly with the steroid dose because its peak action at 4-6 hours aligns with the steroid's peak hyperglycemic effect 1, 2
• Hydrocortisone causes disproportionate hyperglycemia during the day, with glucose often normalizing overnight, making NPH's intermediate-acting profile ideal 1, 2

Dosing Strategy

• NPH is typically administered in addition to basal-bolus insulin if the patient requires comprehensive coverage 1
• For higher doses of glucocorticoids, increasing doses of prandial and correctional insulin are often needed in addition to basal insulin 1
• Avoid sliding-scale insulin as monotherapy - it is ineffective and not recommended 1

Clinical Context and Rationale

Why This Matters for Outcomes

• Hyperglycemia in hospitalized patients is associated with increased mortality, infection rates, and length of stay 1
• Patients with new hyperglycemia (like this case) have significantly increased in-hospital mortality and are more likely to require ICU care 1
• Surgical patients with glucose >220 mg/dL have significantly higher infection rates 1

Prevalence and Risk

• Glucocorticoid-induced hyperglycemia occurs in 56-86% of hospitalized patients with and without pre-existing diabetes 2
• The odds ratio for new-onset diabetes in patients treated with glucocorticoids ranges from 1.5 to 2.5 3
• Nearly half (47.1%) of steroid-naive patients develop steroid-induced hyperglycemia 4

Monitoring and Adjustment Protocol

Frequency of Monitoring

• Monitor glucose at least every 2-4 hours while on glucocorticoid therapy 1
• Peak hyperglycemic effects occur 6-9 hours after hydrocortisone administration, making afternoon glucose monitoring particularly important 2
• For glucose levels >180 mg/dL (10 mmol/L), daily monitoring is recommended 2

Critical Adjustment Principle

• Adjustments based on anticipated changes in glucocorticoid dosing and point-of-care glucose results are critical 1
• When steroid doses are reduced, corresponding adjustments to insulin are necessary to prevent hypoglycemia 2

Common Pitfalls to Avoid

Do Not Delay Treatment

• Failure to treat glucocorticoid-induced hyperglycemia often stems from presumed short duration of steroid therapy and overemphasis on fasting glucose only 3
• This patient already has random glucose of 200 mg/dL, which exceeds treatment thresholds regardless of fasting status 1

Do Not Use Inappropriate Insulin Regimens

• Sliding-scale insulin alone is ineffective as monotherapy 1
• Long-acting insulin alone is not appropriate for once-daily short-acting steroids like hydrocortisone 1, 2

Hypoglycemia Prevention

• Establish a plan for treating hypoglycemia before starting insulin 1
• Episodes of hypoglycemia should be tracked 1

Discharge Planning

Follow-Up Requirements

• Patients with hyperglycemia who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge 1
• An A1C should be obtained if not done in the previous 2-3 months 1