How should I manage an 11-year-old receiving prednisolone who has a random blood glucose of 260 mg/dL?

Management of Prednisolone-Induced Hyperglycemia in an 11-Year-Old

This 11-year-old with a random blood glucose of 260 mg/dL on prednisolone requires immediate insulin therapy with NPH insulin given in the morning, starting at 0.3–0.5 units/kg/day, combined with rapid-acting insulin before meals, along with urgent endocrinology referral and monitoring for diabetic ketoacidosis. 1, 2

Immediate Assessment and Risk Stratification

This glucose level (260 mg/dL = 14.4 mmol/L) places the patient at high risk for diabetic ketoacidosis and requires urgent evaluation. 1

• Check capillary ketones immediately—if ketones >2 mmol/L with glucose >15 mmol/L (270 mg/dL), the patient requires direct hospital admission for emergency assessment and management of potential DKA 1
• Assess for classic diabetes symptoms: polyuria, polydipsia, nocturia, weight loss, polyphagia, fatigue, irritability, or behavioral changes 1, 3
• Obtain formal laboratory testing: venous plasma glucose, HbA1c, electrolytes, renal function, and lipase 1
• Do not dismiss this as simple stress hyperglycemia when the glucose is this elevated—treat as steroid-induced diabetes until proven otherwise 3, 2

Diagnostic Confirmation

Steroid-induced diabetes is diagnosed by repeated glucose measurements ≥11.1 mmol/L (≥200 mg/dL) in the setting of steroid use, or a new HbA1c ≥6.5%. 1, 2

• This single random glucose of 260 mg/dL already exceeds the 200 mg/dL threshold, but obtain confirmatory testing with fasting glucose and HbA1c 1, 3
• A random glucose ≥200 mg/dL with classic symptoms confirms diabetes immediately without need for repeat testing 1, 3
• If the patient is symptomatic (polyuria, polydipsia, weight loss), initiate treatment immediately without waiting for confirmatory labs 1, 3

Insulin Therapy Initiation

Start NPH insulin 0.3–0.5 units/kg/day given in the morning simultaneously with the prednisolone dose, plus rapid-acting insulin (insulin aspart or lispro) 0.05–0.1 units/kg before each meal. 1, 2

Rationale for NPH Insulin Choice

• Morning prednisolone peaks 4–6 hours after dosing, producing maximal hyperglycemia in the afternoon and evening (approximately 8 hours post-dose), with glucose typically normalizing overnight 2, 4, 5, 6
• NPH insulin also peaks 4–6 hours after injection, making its pharmacokinetic profile ideal to counter the steroid-induced hyperglycemic window 2, 7
• Long-acting basal insulins (glargine, detemir) provide 24-hour coverage and are excessive for the afternoon/evening hyperglycemia caused by morning prednisolone—they increase overnight hypoglycemia risk 2, 7

Specific Dosing for an 11-Year-Old

• For a typical 11-year-old weighing approximately 35–40 kg, start NPH insulin 10.5–20 units in the morning 1, 2
• Add rapid-acting insulin 1.75–4 units before each meal (breakfast, lunch, dinner) 1
• If the patient is markedly hyperglycemic (glucose ≥250 mg/dL) and symptomatic, they should be treated initially with basal insulin while metformin is initiated and titrated 1

Monitoring Protocol

Check capillary glucose four times daily: fasting, 2 hours after lunch (approximately 2–3 PM), before dinner, and at bedtime. 1, 2

• The 2-hour post-lunch measurement is the most critical reading—it captures the peak steroid effect and should guide insulin dose adjustments 1, 2, 8, 5
• Target glucose range: 100–180 mg/dL (5.6–10.0 mmol/L) throughout the day 1, 2
• Do not rely on fasting glucose alone—this will miss the afternoon/evening peak and lead to undertreatment 1, 2, 4
• Hyperglycemia typically develops within 48 hours of starting high-dose steroids and peaks on day 3 of therapy 8, 6

Insulin Dose Titration

Increase NPH insulin by 2 units every 3 days if afternoon/evening glucose remains >180 mg/dL. 2

• If overnight hypoglycemia occurs (glucose <70 mg/dL), reduce NPH dose by 10–20% 2
• Adjust prandial insulin based on carbohydrate intake and pre-meal glucose readings 1, 2
• When prednisolone dose is tapered or stopped, insulin requirements fall rapidly—failure to reduce insulin promptly can cause severe hypoglycemia 2, 7, 9

Adjunctive Oral Therapy Considerations

Metformin should be initiated alongside insulin if renal function is normal, as it may attenuate other adverse metabolic effects of prednisolone. 1, 2, 7

• Start metformin at 500 mg once or twice daily with meals, titrating up as tolerated 1
• Avoid sulfonylureas (gliclazide) in children due to prolonged hypoglycemia risk 2
• DPP-4 inhibitors or GLP-1 receptor agonists are not FDA-approved for pediatric use and should not be used outside research trials 1

Urgent Referral Criteria

This patient requires urgent pediatric endocrinology referral within 24–48 hours. 1, 3

Immediate Hospital Admission Indicated If:

• Ketones >2 mmol/L with glucose >15 mmol/L (270 mg/dL)—high risk for DKA 1
• Persistent glucose >20 mmol/L (360 mg/dL) or meter reading "HI"—risk for hyperosmolar hyperglycemic state 1, 2
• Clinical signs of DKA: nausea, vomiting, rapid breathing, altered mental status, abdominal pain 1, 3
• Severe dehydration or inability to maintain oral intake 1

Urgent Outpatient Endocrinology Referral Indicated For:

• Any classic diabetes symptoms present 3
• Confirmed steroid-induced diabetes (repeat glucose ≥200 mg/dL or HbA1c ≥6.5%) 1, 3
• Glucose persistently >270 mg/dL despite initial insulin adjustments 1, 2

Patient and Family Education

Provide immediate education on hypoglycemia recognition and management, sick day rules, and ketone monitoring. 1

• Teach recognition of hypoglycemia symptoms: shakiness, sweating, confusion, irritability, hunger 1
• Provide glucagon emergency kit and train caregivers on administration 1
• Instruct on ketone testing if glucose >250 mg/dL or if ill 1
• Warn that glucose levels >360 mg/dL or meter reading "HI" requires immediate emergency department presentation 1, 2
• Emphasize that insulin doses will need frequent adjustment as steroid doses change 2

Critical Pitfalls to Avoid

• Do not wait for fasting hyperglycemia before treating—prednisolone causes afternoon/evening hyperglycemia with normal fasting glucose 1, 2, 4, 5
• Do not use only sliding-scale correction insulin—this is associated with poor glycemic control and is discouraged in all guidelines 2
• Do not rely on point-of-care glucose meters for definitive diagnosis—use venous plasma glucose measured on a calibrated laboratory analyzer 3
• Do not attribute this degree of hyperglycemia to stress alone when the patient is on prednisolone—treat as steroid-induced diabetes 3, 2
• Do not forget to reduce insulin doses when prednisolone is tapered—insulin needs can decline swiftly and cause severe hypoglycemia 2, 7, 9
• Do not use long-acting basal insulin (glargine) as monotherapy for morning prednisolone—it increases nocturnal hypoglycemia risk without adequately covering the afternoon peak 2, 7

Special Considerations for Pediatric Patients

• Pediatric patients with type 1 diabetes have higher rates of severe hypoglycemia (23–28.6%) compared to adults (6.5–15%) 10
• Children can rapidly develop diabetic ketoacidosis—do not delay evaluation while awaiting symptom progression 3
• Consider continuous glucose monitoring if available, as it improves glycemic control and reduces hypoglycemia risk 1
• Glycemic targets should be individualized, but a reasonable target is 5–10 mmol/L (90–180 mg/dL) 1