Prescribing steroid medications to patients with an existing diabetes diagnosis can create quite a minefield. In this video, from our Diabetes Mellitus Essentials course, we take a look at the main considerations when prescribing steroids to this population. You'll find out when (and how long) you need to monitor hyperglycemia and why you should prescribe insulin alongside the steroid.
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[00:00:00] Steroids present a particular challenge for managing blood sugars, especially for patients with underlying diabetes because of increased insulin resistance, which can lead to significant hyperglycemia. The effect of steroids on blood sugars usually occurs about four hours after the dose, that is if patients are taking steroids with breakfast as they're often given, they'll experience hyperglycemia post-lunch. For patients on prednisone, which has a duration of action of 12 hours, the effects will typically wear off
[00:00:30] several hours after dinner so fasting blood sugars are not often affected. For patients on long-acting steroids such as dexamethasone, the hyperglycemia can last for up to 36 hours. When diabetic patients are started on steroids, they should be advised to check their blood sugars one to two hours after dinner for the first few days. If blood sugars are less than 180 mg / dL, they can discontinue monitoring. If blood sugars are elevated above 200 mg / dL, however, they should increase testing to four times daily
[00:01:00] before meals and at bedtime, and you should consider starting treatment for hyperglycemia if blood sugars are consistently elevated throughout the day.The hyperglycemia associated with steroids is primarily post-meal and due to an increase in insulin resistance. For patients without prior diabetes or those with diabetes treated with lifestyle modification only, this can often be managed with oral medications. Metformin can improve insulin resistance and decrease hepatic glucose output. It carries a low risk of hypoglycemia
[00:01:30] so it's safe to continue during steroid tapers. DPP-4 inhibitors and GLP-1 receptor agonists are also reasonable options to consider, as they can decrease post-meal hyperglycemia and are unlikely to cause hypoglycemia. Insulin is the best option for managing steroid-induced hyperglycemia in patients with a previous diagnosis of diabetes. For patients new to insulin, starting a basal-bolus insulin regimen can be complicated and difficult. So, a simple regimen for managing steroid-induced
[00:02:00] hyperglycemia is to add a dose of once-daily basal insulin with breakfast. For patients already on insulin, you can simply increase their basal insulin dose. What insulin should you use? Well, choosing which insulin to use depends on the steroid that the patient is getting. As mentioned earlier, prednisone has a 12-hour duration of action, thus, for patients getting once daily prednisone, their hyperglycemia is best controlled with NPH with breakfast. The peak of NPH is approximately four hours, which corresponds
[00:02:30] to the post-lunch hyperglycemia seen with prednisone. The duration of action also matches the effect of prednisone, which minimizes the risk of overnight hypoglycemia. Patients on longer acting steroids like dexamethasone or twice daily prednisone will need more prolonged coverage than what they would get with NPH. They'll require a 24-hour basal insulin like glargine to cover the effects of the steroids. The dose of insulin can be estimated based on the patient's body weight and the dose of steroids. An initial insulin dose
[00:03:00] would be 0.1 unit / kg per day for every 10 mg of prednisone, or equivalent, up to a maximum of 0.4 unit / kg per day. For example, an 80 kg patient is taking 30 mg of prednisone daily for one week. We would calculate his insulin dose as 0.1 unit for every 10 mg of prednisone, so 0.3 units times his body weight, 80 kg, giving us 24 units of NPH every morning. If you're already on
[00:03:30] insulin, we would simply add this to his home regimen.
It's important to recognize that as steroid doses are tapered, you will need to decrease the insulin dose to minimize the risk of hypoglycemia. A good rule of thumb is to decrease the basal insulin by 0.1 unit / kg per day for every 10 mg decrease in steroid dose. Steroid- induced hyperglycemia can be a significant problem for patients on long-term steroid treatment. Be sure to monitor blood sugars for these patients and intervene to treat their
[00:04:00] hyperglycemia, if needed, to prevent complications from high blood sugars.