Should Steroids Be Held in Severe Hyperglycemia (Blood Glucose >500 mg/dL)?
No, steroids should not be held when blood glucose exceeds 500 mg/dL—instead, aggressive insulin therapy must be initiated immediately while continuing the steroid if clinically indicated for the underlying condition. 1
Immediate Management Priority
The critical error would be discontinuing necessary steroid therapy due to hyperglycemia. The guidelines are clear that steroid-induced hyperglycemia is managed with insulin intensification, not steroid withdrawal. 1, 2, 3
For Blood Glucose >500 mg/dL (>27.8 mmol/L):
- This represents Grade 4 toxicity requiring hospital admission for intravenous insulin therapy, volume resuscitation, and evaluation for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state. 1
- Continuous insulin infusion is the preferred regimen for severe steroid-induced hyperglycemia, particularly when glucose exceeds 500 mg/dL. 1
- Check for ketoacidosis immediately—if present, treat as DKA with continuous IV insulin per standard protocols. 1
Why Steroids Should Continue
The underlying principle is that steroid-induced hyperglycemia is a manageable complication, not a contraindication to steroid therapy. 1, 2
- Steroids cause hyperglycemia through impaired beta-cell insulin secretion, increased insulin resistance, and enhanced hepatic gluconeogenesis—all reversible with appropriate insulin therapy. 2, 3
- The American Association of Clinical Endocrinologists explicitly recommends intensifying diabetes treatment with insulin rather than discontinuing steroids. 2
- For patients requiring high-dose steroids (e.g., 50-80 mg prednisone equivalent), extraordinary amounts of insulin are often needed but are effective. 3
Insulin Management Algorithm
Acute Phase (Glucose >500 mg/dL):
- Admit to hospital for continuous IV insulin infusion targeting glucose 140-180 mg/dL (7.8-10.0 mmol/L). 1
- Monitor glucose every 1-2 hours initially, then every 2-4 hours once stable. 1, 3
- Correct electrolytes, particularly potassium (hypokalaemia occurs in ~50% of cases and severe hypokalaemia <2.5 mEq/L increases mortality). 1
Transition to Subcutaneous Insulin:
Once stable (glucose <250 mg/dL for 4-6 hours, no acidosis, hemodynamically stable):
- Start NPH insulin 0.3-0.5 units/kg/day given in the morning to match the afternoon/evening peak hyperglycemic effect of morning steroid doses. 2, 3, 4
- Add rapid-acting prandial insulin at 1 unit per 10-15 grams of carbohydrate before meals. 3
- For very high steroid doses (>50 mg prednisone equivalent), expect to need 40-60% higher insulin doses. 3
Critical Monitoring Points
- Do not rely on fasting glucose alone—this misses the peak hyperglycemic effect occurring 6-9 hours after morning steroid administration. 2, 3, 4
- Monitor glucose four times daily: fasting and 2 hours after each meal. 2, 3, 4
- Peak hyperglycemia typically occurs in the afternoon/evening (around 2-6 PM for morning steroid doses). 2, 3, 5
Steroid Dose Adjustment Considerations
As steroids are tapered, insulin doses must be proportionally decreased to prevent hypoglycemia—this is a common pitfall. 2, 3, 4
- Insulin requirements can decline rapidly after steroid discontinuation. 1
- Adjust insulin downward by the same percentage as steroid dose reduction. 3
Common Pitfalls to Avoid
- Holding steroids instead of treating hyperglycemia—this denies patients necessary anti-inflammatory therapy for a treatable complication. 1, 2
- Relying solely on oral antidiabetic agents for high-dose steroid therapy—these are insufficient. 2, 4
- Using only sliding-scale correction insulin without scheduled basal/prandial insulin—this leads to poor glycemic control. 3
- Failing to reduce insulin when steroids are tapered—this causes hypoglycemia. 2, 3, 4