Immediate Insulin Dose Adjustment for Corticosteroid‑Induced Hyperglycemia

Increase your Lantus dose by 20–30% immediately (from 18 U to approximately 22–24 U once daily) and add 6–8 U of Novolog before lunch and dinner to counteract the afternoon/evening glucose peak caused by morning corticosteroid dosing. 1

Understanding Corticosteroid‑Induced Hyperglycemia

Bilateral knee corticosteroid injections cause systemic absorption that peaks 4–12 hours post‑injection and produces disproportionate hyperglycemia during the afternoon and evening, with glucose often normalizing overnight regardless of treatment. 1
Glucocorticoids induce insulin resistance in the liver, adipocytes, and skeletal muscle, while simultaneously impairing pancreatic β‑cell insulin secretion—requiring 40–60% increases in prandial and correction insulin beyond baseline needs. 1, 2, 3
The hyperglycemic effect typically persists for 24–72 hours after a single intra‑articular injection, then gradually resolves as the steroid is metabolized. 4

Immediate Basal Insulin Adjustment

Increase Lantus from 18 U to 22–24 U once daily (a 20–30% increase) to address the systemic insulin resistance induced by corticosteroid absorption. 1, 2
Titrate basal insulin by 4 U every 3 days if fasting glucose remains ≥180 mg/dL after the initial increase, targeting a fasting range of 80–130 mg/dL. 1
Do not exceed 0.5 U/kg/day of basal insulin (approximately 40–50 U for most adults) without adding prandial coverage, to avoid "over‑basalization" and increased hypoglycemia risk. 1

Adding Prandial Insulin for Afternoon/Evening Hyperglycemia

Start Novolog 6–8 U before lunch and 6–8 U before dinner to counteract the afternoon/evening glucose peak caused by morning corticosteroid dosing. 1, 2
Administer Novolog 0–15 minutes before meals (ideally immediately before eating) for optimal post‑prandial control. 1
Increase each meal dose by 2 U every 3 days based on 2‑hour post‑prandial glucose readings, targeting post‑prandial glucose <180 mg/dL. 1

Correction Scale Adjustment

Use a more aggressive correction scale during the steroid effect period:
- Pre‑meal glucose 201–250 mg/dL → add 4 U Novolog (instead of the usual 2 U). 1
- Pre‑meal glucose 251–350 mg/dL → add 6 U Novolog (instead of the usual 4 U). 1
- Pre‑meal glucose >350 mg/dL → add 8 U Novolog and evaluate for ketones. 1
These correction units are in addition to the scheduled prandial dose, not a replacement. 1

Monitoring Protocol During Steroid Effect

Check fasting glucose daily to guide basal insulin adjustments. 1
Measure pre‑meal glucose before lunch and dinner to calculate correction doses. 1
Obtain 2‑hour post‑prandial glucose after lunch and dinner to assess prandial adequacy and guide further titration. 1
Monitor for hypoglycemia 48–72 hours after the corticosteroid injection, as the steroid effect wanes and insulin requirements drop sharply. 4

Tapering Insulin as Steroid Effect Resolves

Reduce Lantus back to 18 U (or lower) once fasting glucose consistently falls below 100 mg/dL for 2–3 consecutive days, typically 48–72 hours post‑injection. 1, 4
Discontinue prandial Novolog when pre‑meal glucose consistently remains <140 mg/dL without correction doses. 1
Reduce insulin doses by 10–20% immediately if any glucose reading falls <70 mg/dL during the taper. 1

Carbohydrate Coverage Considerations

Do not add carbohydrate coverage (i.e., insulin‑to‑carbohydrate ratio dosing) during the acute steroid effect, as the primary issue is insulin resistance, not carbohydrate intake. 1, 2
Scheduled prandial insulin doses (6–8 U before lunch and dinner) provide adequate coverage for typical meals during the steroid effect period. 1
Carbohydrate counting can be reintroduced once the steroid effect resolves and insulin requirements stabilize. 1

Expected Clinical Outcomes

With appropriate basal and prandial insulin adjustments, glucose should fall to 140–180 mg/dL within 24–48 hours of initiating the intensified regimen. 1
Total daily insulin requirements may increase by 40–60% during the peak steroid effect (e.g., from 23 U/day baseline to 35–40 U/day). 1, 2
Glucose typically normalizes within 48–72 hours after a single intra‑articular corticosteroid injection, allowing insulin doses to be tapered back to baseline. 4

Critical Pitfalls to Avoid

Do not rely solely on correction insulin without increasing scheduled basal and prandial doses; this reactive approach is ineffective and condemned by major diabetes guidelines. 1
Do not delay adding prandial insulin when pre‑meal glucose repeatedly exceeds 180 mg/dL on high‑dose steroids; scheduled prandial coverage is required. 1
Never use rapid‑acting insulin at bedtime as a sole correction dose, as this markedly raises nocturnal hypoglycemia risk. 1
Do not continue the intensified insulin regimen beyond 72 hours without reassessing glucose patterns, as the steroid effect resolves and hypoglycemia risk increases. 1, 4

Alternative Approach: NPH Insulin for Steroid Coverage

If Lantus alone proves insufficient, consider adding 10–15 U NPH insulin at 8 AM (in addition to Lantus) to provide daytime basal coverage that aligns with the steroid's peak effect. 1
NPH given in the morning specifically targets afternoon/evening hyperglycemia caused by morning corticosteroid dosing. 1
This approach may be preferable if the patient has difficulty with multiple daily prandial injections. 1

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