Is it safe for adults with Type 1 (T1DM) or Type 2 (T2DM) diabetes to take steroids?

Can Diabetics Take Steroids?

Yes, diabetics can take steroids when medically necessary, but they require intensive glucose monitoring and proactive insulin therapy adjustments to prevent severe hyperglycemia and its complications. 1, 2

Understanding the Risk

Steroids cause hyperglycemia through multiple mechanisms—they impair insulin secretion, increase insulin resistance, and enhance hepatic glucose production. 1 The hyperglycemic effect is dose-dependent and follows a predictable pattern: blood glucose peaks 4-6 hours after steroid administration (typically afternoon/evening for morning doses) and often normalizes overnight. 1, 3 Steroid-induced hyperglycemia occurs in 56-86% of hospitalized patients, regardless of pre-existing diabetes status. 1

When Steroids Are Necessary Despite Diabetes

Steroids should not be withheld from diabetic patients when clinically indicated—the key is anticipating and managing the hyperglycemia proactively rather than avoiding necessary treatment. 4, 2 This includes situations like:

• Cancer treatment regimens requiring glucocorticoids 4
• Immune-related adverse events from checkpoint inhibitors 4
• Severe inflammatory conditions requiring immunosuppression 2

Mandatory Monitoring Protocol

Monitor blood glucose four times daily: fasting and 2 hours after each meal. 1 This is critical because:

• Fasting glucose alone will miss the peak hyperglycemic effect 1, 3
• Afternoon and evening readings (2-4 PM and 6-8 PM) capture the steroid's maximal impact 1
• Target range should be 90-180 mg/dL (5-10 mmol/L) 1

Treatment Algorithm

For Patients With Pre-existing Diabetes

Immediately add NPH insulin at 0.3-0.5 units/kg/day given in the morning simultaneously with the steroid dose. 1, 3 This matches the pharmacokinetics of intermediate-acting steroids like prednisone or methylprednisolone. 3

Increase existing prandial insulin by 40-60% above baseline doses. 1 For high-dose glucocorticoids (e.g., methylprednisolone 250mg or prednisone ≥40mg), even higher increases may be necessary. 1, 3

Do not rely on oral antidiabetic agents alone for high-dose steroid therapy—insulin is required. 1 However, continue baseline oral medications (like metformin) if not contraindicated. 1

For Patients Without Pre-existing Diabetes

Initiate insulin therapy if blood glucose exceeds 180 mg/dL on two or more occasions. 1 Start with NPH insulin 0.1-0.2 units/kg/day in the morning. 3

Monitor for diabetic ketoacidosis (DKA) in patients developing new-onset hyperglycemia, particularly if they have undiagnosed type 1 diabetes or checkpoint inhibitor-associated diabetes. 4

Special Steroid Scenarios

Long-acting Steroids (Dexamethasone)

Use long-acting basal insulin (glargine or detemir) in addition to NPH because dexamethasone causes sustained hyperglycemia affecting fasting glucose. 1, 3

Nighttime Steroid Dosing

Switch from NPH to long-acting basal insulin given at bedtime when prednisone is administered at night, as the hyperglycemic pattern shifts to overnight and the following day. 3

Multiple Daily Steroid Doses

Long-acting basal insulin becomes essential to control fasting glucose, with additional prandial coverage as needed. 1, 3

Critical Adjustments During Steroid Taper

Reduce insulin doses proportionally as steroid doses decrease to prevent hypoglycemia. 1, 3 This is a common pitfall—insulin requirements drop rapidly after steroid reduction. 3

• For a 50% steroid dose reduction, decrease NPH by 20-40% 3
• Monitor glucose closely during taper (every 2-4 hours initially) 1
• Insulin sensitivity improves within days of steroid dose reduction 3

Common Pitfalls to Avoid

Never rely solely on fasting glucose to guide treatment—this leads to under-treatment of daytime hyperglycemia and potential nocturnal hypoglycemia. 1, 3

Never use sliding-scale correction insulin alone—this approach is associated with poor glycemic control and has been discouraged in guidelines. 3, 5 Scheduled basal-bolus insulin is required. 5, 6

Never delay insulin initiation while waiting for fasting hyperglycemia to develop—by then, severe daytime hyperglycemia has already occurred. 3

Never forget to reduce insulin when tapering steroids—this causes dangerous hypoglycemia. 1, 3

Endocrinology Consultation

Consult endocrinology for patients on high-dose steroids (≥40mg prednisone equivalent) who have type 2 diabetes, as insulin initiation and management can be complex. 4 Early consultation is particularly important for patients developing checkpoint inhibitor-associated diabetes, which requires lifelong insulin therapy. 4

Special Populations

For elderly patients or those with renal impairment, start with lower insulin doses (0.2-0.3 units/kg/day) due to increased hypoglycemia risk. 1, 7

For patients receiving enteral/parenteral nutrition, calculate nutritional insulin as 1 unit per 10-15 grams of carbohydrate, with NPH given every 8-12 hours to cover continuous feeds. 1

Topical Steroids

Topical steroids rarely cause systemic hyperglycemia unless applied to large surface areas or with very potent formulations. 7 However, monitor glucose more frequently (4 times daily) during treatment with potent topical steroids, particularly checking 2-4 hours after application when hyperglycemic effect is maximal. 7