Hyperglycemia as a Result of High-Dose Steroid Therapy
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Patients being treated with high doses of glucocorticoids commonly develop marked hyperglycemia. Glycemic control is often effectively accomplished through CII in the following hospital settings:
- Neurosurgery
- Treatment of cerebral edema
- Exacerbations of asthma
- Treatment of malignancies
- As immunosuppressive therapy for complications of rheumatologic diseases, such as systemic lupus
- Transplant rejection
Hyperglycemia induced by glucocorticoid treatment typically manifests as a minimal elevation in fasting glucose values, a pronounced elevation in postprandial levels, and insensitivity to exogenous insulin. The degree of hyperglycemia observed correlates to the preexisting status of glucose tolerance. Patients with preexisting diabetes may experience marked hyperglycemia. Ketosis is rare, however.25 If large doses of glucocorticoids are given in the morning, hyperglycemia in the late afternoon and evening may be particularly difficult to control.
Hirsch and Paauw25 recommend that the patient who is receiving a stable dose of steroid and has fasting blood glucose (FPG) levels over 200 mg/dL be treated with an emphasis on preprandial short-acting insulin.
In patients in whom the FPG levels are under 200 mg/dL, appropriate therapy may be diet and an oral antihyperglycemic agent such as an alpha-glucosidase inhibitor, metformin, or a thiazolidinedione.
In order to avoid hypoglycemia when steroid doses are tapered, it is important to consider lowering insulin doses proactively, in anticipation of improvement in glucose tolerance. This strategy is particularly important if a large decrease in steroid dose is to be made or if BG levels have been tightly controlled prior to the dose reduction. Case 1 of this eGrand Rounds offers further details.
