Best Practices for Managing Steroid-Induced Hyperglycemia
March 11, 2024
Innovations in Diabetes & Metabolic Care | Winter 2024
Widely prescribed for their anti-inflammatory and immunosuppressive properties, glucocorticoids (steroids) are a critical component of many medical treatment protocols. They are of particular significance for individuals requiring organ transplant, undergoing cancer treatment or coping with chronic pulmonary disease. However, high-dose or long-term use is associated with the risk of developing Type 2 diabetes because steroids cause both insulin resistance and hyperglycemia.
According to a meta-analysis published in “Nature Review Endocrinology,” among patients with no prior history of DM who were prescribed steroids for a month or longer, the incidence of steroid-induced hyperglycemia was 32 percent. The incidence of developing DM was 19 percent. Similarly, individuals with previously well-managed DM may experience dysregulated glucose levels if they require a course of steroids.
“It can be overwhelming for patients dealing with significant health challenges to learn they have to adopt a whole new regimen to manage their blood sugar,” says Lucy Colo, MSN, RN, CDCES, a Diabetes Educator within the University Hospitals Diabetes and Metabolic Care Center. While not everyone will require insulin, Colo works with patients to build an understanding of steroid-induced hyperglycemia.
“I start by getting individuals involved in learning how to monitor their blood sugar and what targets to look for,” she says. “I reassure them that, as steroids taper, there can be less need for insulin. Typically, glucose levels begin to improve — but it does take time to get there.”
Optimal Glucose Management
Commonly prescribed steroids include prednisone, dexamethasone and hydrocortisone. Prednisone can begin triggering hyperglycemia within four hours and may last up to 12 hours, whereas dexamethasone can last from 12 to 36 hours. Hydrocortisone taken orally has a relatively short half-life, typically lasting in the body for six hours.
When patients at University Hospitals Cleveland Medical Center are at risk for steroid-induced hyperglycemia, the endocrinology team is typically consulted to help with glucose management because many of these patients are new to insulin and/or need frequent changes to their insulin regimen as their steroid dose changes. While many factors drive up blood sugar in the inpatient setting, patients on steroids often have glucose levels greater than 200 mg/dL. Colo and her colleagues strive to keep patients’ glucose levels between 140 and 180 mg/dL.
Prednisone dosing is often paired with NPH insulin because the drugs have similar onset, peak and duration. “For someone taking steroids twice a day, a long-acting insulin like glargine might be given to cover them a bit better,” says Colo. “Steroids have a cumulative effect on blood sugar, so initiating insulin therapy on the same day as the initial steroid dose provides much better glycemic outcomes.”
Furthermore, steroids cause significant postprandial hyperglycemia. These patients usually require rapid-acting insulin with meals to combat this rise in blood glucose. It is not uncommon for patients to have much larger mealtime insulin requirements than their basal insulin requirements.
Patient Resources
Colo estimates that about 25 percent of her caseload involves providing education and support to patients experiencing steroid-induced hyperglycemia. She employs a variety of learning tools to help patients adjust to the complexities of glucose self-management. Colo and her colleagues have also developed a diabetes handbook and other user-friendly resources.
“We created a sliding scale that can be individualized for patients to reference,” she says. “It helps clarify how many units of rapid-acting insulin are needed based on their current glucose range.” Members of the endocrinology team also collaborated with oncology Advanced Practice Providers to produce a handout geared specifically for steroid-induced hyperglycemia. “It is an abbreviated version of our diabetes handbook,” says Colo. “I use it with many of my patients because it is not overwhelming and is a great quick reference they can keep at their fingertips.”
Transition to Home
As patients transition home and schedule outpatient follow-up, the endocrinology team works to coordinate care. “For transplant patients, someone from endocrinology will typically go to the transplant clinic for their first visit to review glucose numbers,” says Colo.
Many patients are discharged with a continuous glucose monitor (CGM). Although the devices are not yet Food and Drug Administration (FDA)-approved for tracking inpatient blood sugar use, they “ … are particularly helpful for people who are new to self-managing insulin,” says Colo. “They provide real-time updates of glucose levels and can sync to smartphones.”
University Hospitals’ novel Meds 2 Beds and Pharmacy Platinum Plan programs ensure patients receive needed insulin, supplies and CGMs prior to discharge. “We have a great working relationship with the pharmacists,” says Colo. Often, they will unbox CGMs with patients and show them how the device operates. They also provide close outpatient follow-up via telemedicine and help titrate insulin levels as steroid doses change throughout recovery.
While steroid-induced hyperglycemia can cause additional burdens for medically complex patients, best-practices care helps build knowledge and confidence. “Patients do better when we take the time to explain the effects of steroids and the benefits of insulin,” says Colo. “When we are able to keep blood glucose within target range as much as possible, patients feel better and heal faster.”
For more information about steroid-induced hyperglycemia care at University Hospitals, call (440) 703-8676.
Contributing Expert:
Lucy Colo, MSN, RN, CDCES
Diabetes Educator
University Hospitals Diabetes and Metabolic Care Center
University Hospitals Cleveland Medical Center