From the Guidelines
Management of hyperglycemia in diabetic patients on high-dose steroid therapy requires an aggressive approach with frequent monitoring and medication adjustments, as outlined in the most recent guidelines 1. For patients already on diabetes medications, the dose of their current regimen should be increased by 20-40% when starting steroids. For insulin users, the focus should be on increasing the intermediate or long-acting insulin (like NPH, glargine, or detemir) by 20-50% depending on the steroid dose, with NPH insulin being a preferred choice due to its peak action aligning well with prednisolone's hyperglycemic effect 1. Key points to consider in management include:
- Monitoring blood glucose 4-6 times daily, especially after meals when steroid-induced hyperglycemia is most pronounced.
- Targeting fasting glucose of 80-130 mg/dL and postprandial levels below 180 mg/dL.
- For steroid-naïve diabetic patients starting high-dose therapy, initiating insulin at 0.3-0.5 units/kg/day, with approximately 60-70% as basal insulin, and adjusting insulin doses every 1-2 days based on glucose patterns.
- Proportionally reducing insulin or oral medications as steroid doses taper to prevent hypoglycemia, as supported by recent guidelines 1. This approach is necessary because steroids significantly worsen hyperglycemia by increasing insulin resistance and hepatic glucose production while impairing insulin secretion, effects that are most pronounced 4-8 hours after steroid administration 1.
From the FDA Drug Label
A number of substances affect glucose metabolism and may require insulin dose adjustment and particularly close monitoring The following are examples of substances that may reduce the blood-glucose-lowering effect of insulin: corticosteroids, danazol, diuretics, sympathomimetic agents (e.g., epinephrine, albuterol, terbutaline), isoniazid, phenothiazine derivatives, somatropin, thyroid hormones, estrogens, progestogens (e.g., in oral contraceptives).
The management of hyperglycemia in diabetic patients undergoing high-dose steroid therapy may require insulin dose adjustment and close monitoring of blood glucose levels, as corticosteroids can reduce the blood-glucose-lowering effect of insulin 2.
- Key considerations include:
- Monitoring blood glucose levels frequently
- Adjusting insulin doses as needed to maintain glycemic control
- Being aware of the potential for reduced blood-glucose-lowering effect of insulin when used with corticosteroids.
From the Research
Management of Hyperglycemia in Diabetic Patients Undergoing High-Dose Steroid Therapy
- The management of hyperglycemia in diabetic patients undergoing high-dose steroid therapy is crucial to prevent complications associated with hyperglycemia 3, 4.
- Studies have shown that insulin therapy is effective in reducing hyperglycemia in patients receiving high-dose steroids, with a median insulin dose of 1-1.3 units/kg per cycle 3.
- The distribution of basal versus bolus insulin is important, with 63-77% prandial and 23-37% basal insulin being used in one study 3.
- Another study found that initiating higher bolus insulin at lunch and dinner, with an additional enhanced steroid-specific insulin supplemental scale, may be needed to adequately treat large dinner and bedtime steroid-exacerbated glycemic excursions 4.
- The use of SGLT2 inhibitors and GLP-1 receptor agonists may also be beneficial in managing hyperglycemia in patients with type 2 diabetes, with additional benefits of weight loss and blood pressure reduction 5, 6, 7.
Insulin Therapy
- Insulin therapy is associated with weight gain and increased risk of hypoglycemia, but adding other antidiabetes medications to insulin can improve glycemic control and potentially lower the required insulin dose 7.
- GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors improve glycemic control when added to insulin and have a low propensity for hypoglycemia and cause no change or a reduction in body weight 7.
Steroid-Exacerbated Hyperglycemia
- Steroid-exacerbated hyperglycemia is prevalent in hospitalized patients with diabetes mellitus, and evidence-based insulin guidelines in inpatient settings are lacking 4.
- A study found that GC-exacerbated hyperglycemia was greatest at dinner and bedtime, and that initiating higher bolus insulin at lunch and dinner may be needed to adequately treat these excursions 4.