Management of Glucocorticoid-Induced Hyperglycemia

Abstract

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.

Medication Management in Patients with Polypharmacy

“…Metformin was not sufficient to maintain a fingerstick glucose range (70-140), so glipizide was later added. It is well known that blood glucose levels rise about 4 hours after taking oral steroids (Shah et al, 2022).…”

“…The rehab nurse with Brian alerted his PCP, and a staff pharmacist with diabetic drug expertise was consulted: Metformin was increased to maximum 2,500 mg daily; a maximum 40-mg glipizide was added (Shah et al, 2022). -The rehab nurse discovered contraindication between myasthenia gravis and metoprolol (Lopressor).…”

Insulin pumps in children - a systematic review

“…Interestingly, the daily timing of steroid-induced hyperglycemia depends on the type of steroid use. For example, prednisolone, usually given in the morning, induces hyperglycemia in the late morning and persists into the evening with a gradual fall of blood glucose back overnight, often reaching baseline levels the following morning[ 86 ]. Therefore, children on pump therapy need to increase the basal insulin rate to 130%-150% during the expected times of maximal hyperglycemia.…”

Nutritional recommendations during long-term administration of glucocorticoids

“…Ovaj problem je često potcenjen, međutim GC mogu biti uzrok novonastalog dijabetesa ili pogoršanja glikemije kod osoba sa prisutnim predijabetesom, što povećava rizik od lošeg kliničkog ishoda bolesti, pojave infekcije, komorbiditeta ili može biti uzrok produžene hospitalizacije i povećanih troškova. Pre započinjanja GC lečenja neophodan je detaljan skrining rizika za pojavu dijabetesa, a zatim redovno praćenje glikemije i eventualno povećanje doze oralnih hipoglikemijskih agensa, uz strože dijetetske preporuke ili čak uvođenje lečenja insulinom, uz konstantno praćenje i modifikaciju doze lekova da bi se izbegle eventualne komplikacije (hipoglikemija) prilikom smanjivanja doze GC (30).…”