Management of Steroid-Induced Hyperglycemia in Acute Ulcerative Colitis
The patient requires initiation of metformin for steroid-induced hyperglycemia, with consideration for dose reduction or discontinuation of prednisone as soon as clinically feasible, given the patient is already on Rinvoq 45mg which should be providing disease control. 1, 2
Immediate Glycemic Management
Metformin 500-850mg once or twice daily should be initiated as first-line therapy for this patient with prediabetes (A1C 6.2%) and mild hyperglycemia (glucose 111 mg/dL), which is clearly steroid-induced given the high-dose prednisone 35mg daily. 1
The glucose of 111 mg/dL and A1C of 6.2% represent prediabetes with mild hyperglycemia that warrants pharmacologic intervention in the context of ongoing high-dose corticosteroid therapy. 1
Lifestyle modifications alone are insufficient when patients are on supraphysiologic doses of corticosteroids, as the hyperglycemic effect will persist throughout the steroid course. 1
Critical Steroid Management Considerations
The prednisone dose of 35mg daily should be tapered aggressively over the next 6-8 weeks, as the patient is already on therapeutic-dose Rinvoq 45mg for ulcerative colitis. 1, 2
The British Society of Gastroenterology guidelines recommend prednisolone 40mg daily with tapering over 6-8 weeks for moderate to severe ulcerative colitis, but this patient is already on advanced therapy with upadacitinib. 1
Rinvoq (upadacitinib) 45mg is FDA-approved for moderately to severely active ulcerative colitis and should be providing disease control, making prolonged high-dose corticosteroids unnecessary and potentially harmful. 2
The FDA label explicitly states that Rinvoq is not recommended for use with potent immunosuppressants, though short-term corticosteroid bridging is acceptable during induction. 2
Steroid Tapering Protocol
Begin tapering prednisone by 5mg weekly once clinical improvement is evident, typically starting immediately if the patient has been on Rinvoq for at least 2-4 weeks. 1
More rapid steroid reduction is associated with early relapse, so the taper should be gradual but deliberate, generally completed over 8 weeks maximum. 1
The goal is complete steroid discontinuation, as the upadacitinib should maintain remission as monotherapy. 2
Monitoring Requirements During Treatment
Recheck fasting glucose and A1C in 8-12 weeks after initiating metformin and as prednisone is tapered, as glycemic control should improve significantly with steroid reduction. 1
Monitor for metformin side effects including gastrointestinal symptoms (nausea, diarrhea), which occur in up to 30% of patients but typically resolve with continued use or dose adjustment. 1
Check renal function (eGFR) before starting metformin and monitor periodically, as metformin is contraindicated with eGFR <30 mL/min/1.73m² and requires dose adjustment with eGFR 30-45 mL/min/1.73m². 1
Alternative Glycemic Management if Metformin Insufficient
If glucose control remains inadequate on metformin alone while still on prednisone, consider adding a DPP-4 inhibitor (sitagliptin 100mg daily) or GLP-1 receptor agonist rather than insulin, as these have lower hypoglycemia risk. 1
Short-acting insulin (sliding scale) may be necessary if glucose exceeds 200 mg/dL consistently, but this is unlikely with the current mild elevation. 1
Critical Safety Considerations
The combination of Rinvoq 45mg and prednisone 35mg carries significant infection risk and should not be prolonged beyond the minimum necessary for disease control. 2
The FDA label warns that JAK inhibitors like upadacitinib increase risk of serious infections, malignancies, cardiovascular events, and thrombosis, which are compounded by concurrent corticosteroid use. 2
Patients on this combination require monitoring for signs of infection including fever, chills, or new symptoms, with immediate evaluation if these occur. 2
The risk of gastrointestinal perforation is elevated with both corticosteroids and JAK inhibitors, particularly in patients with active ulcerative colitis, requiring vigilance for new abdominal pain, fever, or change in bowel symptoms. 2
Long-Term Disease Management Strategy
Once prednisone is discontinued, Rinvoq 45mg should be continued as monotherapy for induction, with potential dose reduction to 15mg or 30mg for maintenance therapy after achieving clinical remission. 2, 3
Patients without clinical response after 8 weeks of upadacitinib 45mg may benefit from an additional 8 weeks at the same dose before considering alternative therapies. 3
The British Society of Gastroenterology recommends that patients requiring two or more courses of corticosteroids per year or becoming steroid-dependent should receive treatment escalation, which has already been accomplished with upadacitinib. 1