Can steroid premedication be given to a patient with asthma and comorbid Diabetes Mellitus (DM) undergoing elective surgery?

Steroid Premedication in Asthmatic Diabetic Patients Undergoing Elective Surgery

Yes, steroid premedication can be given to asthmatic patients with diabetes mellitus undergoing elective surgery, but requires aggressive perioperative glucose management with increased insulin dosing (often 40-60% or more above baseline) and close monitoring to prevent hyperglycemia while avoiding hypoglycemia. 1

Key Principles for Perioperative Steroid Management

Asthma-Specific Considerations

• All asthmatics who required systemic or inhaled corticosteroids within 6 months prior to surgery must receive perioperative corticosteroid coverage to prevent adrenal crisis and bronchospasm. 2
• Patients on chronic steroids (≥4 weeks of use) should receive equivalent intravenous hydrocortisone while unable to take oral medications, using standard conversion ratios: Prednisolone 5 mg = Hydrocortisone 20 mg = Methylprednisolone 4 mg. 3, 4
• A single preoperative dose of dexamethasone 4 mg IV/IM may be given without increasing steroid dosage to cover perioperative stress, as demonstrated in randomized trials. 3

Diabetes Management During Steroid Administration

The critical challenge is managing steroid-induced hyperglycemia, not whether to give steroids. The following approach is essential:

• Target perioperative blood glucose of 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery. 1
• For patients receiving intermediate-acting steroids (like prednisone), administer NPH insulin concomitantly, as NPH peaks 4-6 hours after administration, matching the steroid's hyperglycemic effect. 1
• For long-acting glucocorticoids (dexamethasone) or continuous steroid use, long-acting basal insulin is required to manage fasting glucose levels. 1
• Increase prandial and correctional insulin doses by 40-60% or more above baseline when higher-dose glucocorticoids are used. 1

Preoperative Optimization

• Target A1C <8% (63.9 mmol/L) for elective surgeries whenever possible. 1
• If diabetes is poorly controlled (A1C >8%), consider delaying elective surgery for glycemic optimization, as poor control increases risk of asthma exacerbations and surgical complications. 5
• Monitor blood glucose at least every 2-4 hours while the patient is NPO and dose with short- or rapid-acting insulin as needed. 1

Evidence-Based Algorithm for Decision-Making

Step 1: Assess Steroid Necessity

• If patient has used systemic or inhaled steroids within 6 months before surgery → Perioperative steroid coverage is mandatory 2
• If patient is on chronic steroids (>4 weeks) → Continue therapy with IV equivalent dosing perioperatively 3, 4

Step 2: Glycemic Risk Stratification

• Well-controlled diabetes (A1C <7%): Expect moderate hyperglycemia; standard insulin dose increases (40-60%) usually sufficient 1
• Poorly controlled diabetes (A1C >8%): Expect severe hyperglycemia; may require insulin increases >60% and more frequent monitoring 6

Step 3: Steroid Selection and Timing

• Single-dose dexamethasone 4 mg IV preoperatively is acceptable and does not significantly worsen glycemic control in well-controlled diabetics 7
• In nondiabetics, dexamethasone increases glucose by approximately 29 mg/dL; this effect is minimal in diabetics who already have impaired glucose regulation 7
• Avoid denying steroid prophylaxis for PONV solely due to diabetes, as the hyperglycemic effect is manageable with appropriate insulin adjustment 7

Step 4: Insulin Management Protocol

• Hold metformin on day of surgery 1
• Hold SGLT2 inhibitors 3-4 days before surgery 1
• Give 50% of NPH dose or 75-80% of long-acting insulin analog on morning of surgery 1
• Initiate basal-bolus insulin regimen perioperatively (superior to correction-only insulin) 1
• Daily adjustments based on glycemia levels and anticipated changes in steroid type, dosage, and duration are critical 1

Important Caveats and Pitfalls

Common Errors to Avoid

• Do not withhold necessary steroid coverage due to fear of hyperglycemia - the risk of adrenal crisis and bronchospasm in undertreated asthmatics far exceeds the manageable risk of transient hyperglycemia 2
• Do not use correction-only insulin without basal coverage - this approach leads to worse glycemic outcomes and higher complication rates 1
• Do not assume inhaled steroids at low doses significantly affect glucose - daily budesonide up to 825 mcg has no significant influence on fasting glucose 8

Monitoring Requirements

• Point-of-care glucose monitoring every 2-4 hours while NPO, then every 4-6 hours postoperatively 1
• Do not use CGM alone for glucose monitoring during surgery 1
• Watch for both hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL), as increasing insulin-to-steroid ratios improves time in range but increases hypoglycemia risk 1

Postoperative Considerations

• Resume oral steroids when feasible, transitioning from IV hydrocortisone back to oral prednisolone as soon as patient tolerates oral intake 3
• Implement standardized taper protocols to avoid inappropriate prolongation of steroids after surgery 3
• Monitor for wound healing complications, infections, and signs of adrenal insufficiency in patients who received perioperative corticosteroids 3
• Patients on chronic steroids have higher baseline risk for wound complications; careful wound assessment is mandatory 9

Special Population Considerations

Patients with severe asthma and diabetes have worse outcomes - there is a negative relationship between severe asthma and diabetes control, requiring even more aggressive perioperative management 8, 5