management of diabetes risk with high dose steroids

Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021

MANAGEMENT OF DIABETES RISK WITH HIGH DOSE STEROIDS

Adapted from the Joint British Diabetes Societies (JBDS) for Inpatient Care ‘Management of Hyperglycaemia

and Steroid (Glucocorticoid) Therapy’ (2014) and NHS Lothian steroid guidance documents. The guidance is

designed for use in acute (both inpatient and outpatient) and primary care for patients known to have

diabetes and for those who may develop steroid induced diabetes as defined below.

Steroid induced diabetes is defined as a blood glucose > 12 mmol/L on two occasions in a 24 hour period.

Steroid use is defined as glucocorticoid therapy (> 20mg prednisolone or equivalent – see table 1 below) for

greater than 14 days.

Table 1: Steroid Dose Equivalents

Prednisolone 20mg daily approximately equivalent to:

Hydrocortisone 80mg

Dexamethasone 3mg

Methylprednisolone 16mg

Betamethasone 3mg

N.B. potency relates to anti-inflammatory action, which may not equate to hyperglycaemic effect.

NEED FOR A GUIDELINE

The prevalence of long term steroid use is estimated at 0.78% nationally and rising. Multiple observational

and retrospective data sets suggest an incidence of steroid induced diabetes of 18-52%.

There is a risk of the development of hyperosmolar hyperglycaemic state (HHS) or diabetic ketoacidosis (DKA)

in the context of steroid use. These are potentially avoidable complications with associated morbidity and

mortality.

Adherence to this guidance should:-

improve patient safety by preventing patients being admitted to secondary care with the above

diabetes emergencies;

improve potential outcomes in terms of morbidity and mortality;

minimise patients experiencing unnecessary osmotic symptoms due to hyperglycaemia.


RECOMMENDATIONS FOR SCREENING AND MONITORING FOR STEROID INDUCED DIABETES

Will the patient be taking high dose

steroids (Prednisolone > 20mg or

equivalent) for 2 weeks or more?

NO No monitoring required, advise patient of symptoms

(Appendix 1)

YES

Is patient known to have diabetes?

NO YES

Patient to be taught blood glucose monitoring (if not doing already). (This should be done by the practice nurse, Diabetes Centre or inpatient diabetes specialist nurse (DSN) – see notes below)

Blood glucose monitoring For patients requiring to be taught blood glucose monitoring at the Diabetes Centre, please call 01592 648001.

Patients not known to have diabetes should test blood glucose once daily before evening meals for the first 2 weeks of steroid use and record results (appendix 2).

If results are more than 12 mmol/L on 2 consecutive occasions, increase testing to 4 times daily pre meals and consider commencing treatment as per guidance.

If results are all less than 10mmol/L after 2 weeks, change frequency of testing to once per week while taking steroids.

(Test strips should be prescribed acutely then removed once steroid course complete).

Patients known to have diabetes should test 4 times daily pre-meals. The need to continue blood glucose monitoring should be individually assessed once steroid course complete.

Inpatients

Follow above guidance for blood glucose monitoring frequency.

Follow algorithm for treatment guidance.

Advise patient to arrange follow-up with practice nurse or to keep in contact with the DSN if they attend secondary care for their diabetes care.

For inpatients requiring to be taught blood glucose monitoring please call the Inpatient DSN on extension 21364 (please note the DSN will then arrange for the patient to be seen – this may not be on the same day of referral).


TREATMENT ALGORITHM

Patients should be equipped with home blood glucose monitoring and relevant education regarding hypoglycaemia management and driving responsibilities. This is due to the hypoglycaemia risk associated with sulphonylureas (SU) and insulin. Treatment should be tailored on an individual patient basis. This may require the local diabetes service to advise. The standard blood glucose target goal is 6-12 mmol/L.. Patients who are elderly, frail, palliative care, end of life, at risk of falling, eating variably or with impaired hypoglycaemia awareness will require a higher target (8-20 mmol/L). The aim for these patients is to avoid hypoglycaemia and symptomatic hyperglycaemia.

Patients without known DM

Known T2DM not on insulin

Known T2DM on insulin

If on once daily insulin in the evening , change injection to morning and titrate by 10-20% every 2-3 days according to pre-evening meal blood glucose level. If targets are not met consider Humalog 4 units with each meal and titrate by 10-20% every 2-3 days. If on twice daily insulin titrate

morning dose by 10-20% every

2-3 days according to pre-

evening meal blood glucose

level

If on basal bolus insulin titrate

short acting insulin by 10-20%

every 2-3 days

If targets not met titrate Gliclazide rapidly (increments of 40mg every

2-3 days) to a maximum of 240mg in the morning

If targets not met add in Humulin I or Insulatard 10 units in the morning

and titrate by 10-20% every 2-3 days according to pre-evening meal

blood glucose level

If targets not met consider Humalog 4 units with meals and titrate by 10 -

20% every 2-3 days and stop SU (local diabetes service may need to

advise)

Patients on insulin pumps – refer to the Diabetes Centre.

Patients with type 1 diabetes – remind to check ketones if blood glucose > 14 mmol/L and correct if ketones > 0.6 mmol/L.

Blood glucose > 12mmol/L on 2 occasions in 24 hours – consider Gliclazide 40mg in the morning

If no evidence of hyperglycaemia and not on an SU - consider Gliclazide 40mg in the morning. If already on SU - progress to titration if required.


TREATMENT WITHDRAWAL AND FOLLOW-UP

TREATMENT WITHDRAWAL

Gradual reduction in insulin or sulphonylurea (SU) therapy will be required during withdrawal of steroids. This

should be guided by blood glucose monitoring results with particular emphasis on avoidance of hypoglycaemia.

This may require the local diabetes service to advise. (For outpatient advice – contact Diabetes Centre, extension

28001 or 01592 648001).

REDUCING SU

When steroids are reduced it is recommended that SU is reduced by 40mg or 80mg in order to prevent

hypoglycaemia. Dose reduction will depend on patient’s blood glucose levels and SU dose at the time.

REDUCING INSULIN

When steroids are reduced it is recommended that insulin is reduced by 10-20% in order to prevent

hypoglycaemia. Percentage reduction will depend on patient’s blood glucose levels and insulin dose at the time.

NOTE

For some patients SU or insulin may need to be increased despite reduction in steroid dose. This will depend on

patient’s blood glucose levels at the time.

FOLLOW UP

Not known to have diabetes

Patients should continue to monitor blood glucose levels for 2 weeks once steroid course completed to ensure

blood glucose levels return to normal range (4-7 mmol/L).

If blood glucose levels remain elevated post steroids and HbA1c pre-steroid treatment is <48 mmol/mol, patient

should have an oral glucose tolerance test done in primary care 6 weeks post completion of steroid course

Steroid induced diabetes

If blood glucose levels remain elevated post steroids and HbA1c pre-steroid treatment is >48 mmol/mol, patient

should be treated as new diagnosis of type 2 diabetes and treatment initiated as required.

Known to have diabetes

Routine follow up in usual care setting

For inpatients

Contact the inpatient DSN on extension 21364 for advice as required


Appendix 1: Patient information leaflet – Glucose Monitoring For Those Not Known To Have Diabetes

Dear ……………….

Start Date: ...............................

Taking steroid medication can lead to a rise in blood glucose levels which may need to be treated.

Therefore, it is important that you regularly monitor your blood glucose levels.

Please measure your blood glucose levels once daily before your evening meal for the first 2 weeks

of steroid use and complete the table below.

Week 1

DATE

TIME

READING

Week 2

DATE

TIME

READING

If your blood glucose level is greater than 12 mmol/L on 2 consecutive occasions, increase

testing to 4 times daily (before main meals and bed time) and make an appointment with your

practice nurse.

If your blood glucose levels are all less than 12 mmol/L after 2 weeks you can reduce

monitoring to once per week while taking the steroid medication.

If your blood glucose level is over 20 mmol/L and you feel unwell contact your GP surgery or

call NHS 24 (dial 111) for advice out-of-hours.

Additional blood glucose level readings can be recorded here.

DATE

TIME

READING


REFERENCES

1. Joint British Diabetes Societies for inpatient care. Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy, 2014.

2. Umpierrez, G.E., et al., Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab, 2012. 97(1): p. 16-38.

3. Clement, S., et al., Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 2004. 27(2): p. 553-91.

4. Liu, X.X., et al., Hyperglycemia induced by glucocorticoids in nondiabetic patients: a meta-analysis. Ann Nutr Metab, 2014. 65(4): p. 324-32.

5. Donihi, A.C., et al., Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients. Endocr Pract, 2006. 12(4): p. 358-62.

6. Clore, J.N. and L. Thurby-Hay, Glucocorticoid-induced hyperglycemia. Endocr Pract, 2009. 15(5): p. 469-74.

7. Ha, Y., et al., Glucocorticoid-induced diabetes mellitus in patients with systemic lupus erythematosus treated with high-dose glucocorticoid therapy. Lupus, 2011. 20(10): p. 1027-34.

8. Lee, S.Y., et al., Glucocorticoid-induced diabetes mellitus in patients with lymphoma treated with CHOP chemotherapy. Support Care Cancer, 2014. 22(5): p. 1385-90.

9. Iwamoto, T., et al., Steroid-induced diabetes mellitus and related risk factors in patients with neurologic diseases. Pharmacotherapy, 2004. 24(4): p. 508-14.

10. Hwang, J.L. and R.E. Weiss, Steroid-induced diabetes: a clinical and molecular approach to understanding and treatment. Diabetes Metab Res Rev, 2014. 30(2): p. 96-102.

11. Derr, R.L., V.C. Hsiao, and C.D. Saudek, Antecedent hyperglycemia is associated with an increased risk of neutropenic infections during bone marrow transplantation. Diabetes Care, 2008. 31(10): p. 1972-7.

management of diabetes risk with high dose steroids

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