Management of hyperglycaemia and steroid (glucocorticoid) therapy

Joint British Diabetes Societies for Inpatient Care


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Introduction

  • The use of glucocorticoid treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control; this may be termed glucocorticoid-induced hyperglycaemia. This will warrant temporary additional and more active glycaemic management
  • A rise in glucose, related to glucocorticoid therapy occurring in people without a known diagnosis of diabetes is termed glucocorticoid-induced diabetes. This may or may not resolve when the glucocorticoids are withdrawn
  • In the outpatient population, 40% of glucocorticoid use is for respiratory disease, with most of the rest being used in musculoskeletal and cutaneous diseases, and conditions requiring immunosuppression. Most glucocorticoid use is for less than 5 days, but 22% is for greater than 6 months and 4.3% for longer than 5 years
  • Some patients may develop hyperglycaemia at a lower glucocorticoid dose, so clinical vigilance is, therefore, recommended with glucocorticoid therapy at any dose

Predisposing factors leading to increased risk of hyperglycaemia with glucocorticoid therapy

  • Pre-existing type 1 or type 2 diabetes
  • People at increased risk of diabetes (e.g. obesity, family history of diabetes, previous gestational diabetes, ethnic minorities, polycystic ovarian syndrome)
  • Pre-existing impaired fasting glucose or impaired glucose tolerance, HbA1c 42–47 mmol/mol
  • People previously hyperglycaemic with glucocorticoid therapy
  • Those identified to be at risk utilising the University of Leicester/Diabetes UK diabetes risk calculator 

Monitoring guidance

In people without a pre-existing diagnosis of diabetes

  • Monitoring should occur at least once daily—preferably prior to lunch or evening meal, or alternatively
  • 1–2 hours post lunch or evening meal. If the initial blood glucose is less than 12 mmol/l continue to test once prior to or following lunch or evening meal
  • If a subsequent capillary blood glucose is found to be greater than 12 mmol/l, then the frequency of testing should be increased to four times daily (before meals and before bed)
  • If the capillary glucose is found to be consistently greater than 12 mmol/l i.e. on two occasions during 24 hours, then the patient should enter the Management of glucocorticoid-induced diabetes algorithm (see below)

Management of glucocorticoid-induced diabetes

Management of glucocorticoid-induced diabetes

In people with a pre-existing diagnosis of diabetes

  • Test four times a day, before or after meals, and before bed, irrespective of background diabetes control
  • If the capillary glucose is found to be consistently greater than 12 mmol/l, i.e. on two occasions during 24 hours, then the patient should enter the Managing glucose control in people with known diabetes on once daily glucocorticoids algorithm (see below)

Managing glucose control in people with known diabetes on once daily glucocorticoids

Managing glucose control in people with known diabetes on once daily steroids (glucocorticoids)

Type 2 diabetes and glucocorticoid treatment—general guidance

  • Set target for capillary blood glucose (CBG) e.g. 6–10 mmol/l
  • Consider increasing monitoring to 4 times daily
  • Refresh diabetes education with patient
  • If hyperglycaemia on non-insulin therapies:
    • gliclazide—titrate to maximum of 320 mg daily, with maximum 240 mg in the morning
    • metformin—titrate to maximum of 1 g bd
  • If hyperglycaemia on insulin therapies:
    • if on evening once daily human insulin consider switch to morning dosing
    • if uncontrolled hyperglycaemia or multiple daily dosing of glucocorticoid consider switch to basal analogue insulin (or alternative regimen) and involve diabetes team in hospital or community
    • beware of nocturnal and early morning hypoglycaemia

Hospital discharge of patients at risk of glucocorticoid-induced diabetes/hyperglycaemia

Glucocorticoids commenced and patient discharged

  • Standard education for patient and carer
  • Blood glucose testing once daily (pre or post lunch or evening meal)
  • If blood glucose readings greater than 12 mmol/l increase frequency of testing to four times daily
  • If two consecutive blood glucose readings greater than 12 mmol/l in a 24 hour period follow algorithm for management of glucocorticoid-induced diabetes

Patient discharged on decreasing dose of glucocorticoid above 5 mg od

  • Standard education for patient and carer including advice on hypoglycaemia
  • Continue CBG monitoring until blood glucose normalises (4–7 mmol/l)
  • Review by agreed individual (e.g. GP, diabetologist, diabetes specialist nurse, etc) at an appropriate juncture to consider down-titration of antihyperglycaemic therapy if necessary

Patient discharged following glucocorticoid cessation

  • If hyperglycaemia persists:
    • CBG testing until return to normoglycaemia (4–7 mmol/l)
    • or until a definitive diagnosis of diabetes is undertaken
  • If hyperglycaemia resolved, stop CBG testing and arrange definitive test for diabetes

References

full guideline available from...
www.diabetologists-abcd.org.uk/JBDS/JBDS.htm

Joint British Diabetes Societies for Inpatient Care. Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy. October 2014


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