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Manage your patient’s diabetes when they are taking corticosteroids
Giving corticosteroids to someone with diabetes will worsen their glycemic control, so continue to test blood glucose at least four times a day and treat hyperglycemia if it occurs (based on expert opinion).
For patients with diabetes, use the same doses of corticosteroid as for patients without diabetes, but review their diabetes medication. Adjust dose for existing medication or start additional glucose-lowering treatments if needed.
Patients with type 1 diabetes may need their insulin regimen intensifying.
Consider commencing insulin therapy in patients with type 2 diabetes who have high blood glucose levels pre-corticosteroid treatment (based on expert opinion).
If your patient is an inpatient, use an appropriate order set for managing hyperglycemia.[295]
If insulin orders are initiated, review and adjust these daily, taking into account levels of glycemia, and anticipated changes in dose, type, and duration of corticosteroid.[295]
NPH (neutral protamine Hagedorn) insulin may be added to the individual's usual basal-bolus insulin or oral glucose-lowering medication if an intermediate-acting corticosteroid (e.g., prednisone) is initiated. The American Diabetes Association (ADA) recommends administering NPH insulin at the same time as the corticosteroid dose, as the action peak of 4 to 6 hours coincides with peak plasma level of the intermediate corticosteroid.
Long-acting insulin may be needed for an individual starting a long-acting corticosteroid (e.g., dexamethasone), or for those having multiple doses or continuous doses of a corticosteroid.
Increases in correction insulin and prandial insulin (if eating) may be needed, along with basal insulin, for an individual starting a high dose of a corticosteroid.
Be aware of the possibility of nocturnal or early morning hypoglycemia. Consider adjusting basal insulin and avoid bed-time correctional doses of rapid-acting insulin (based on expert opinion).
If a continuous intravenous insulin infusion is being used in a critically ill patient, follow glycemic management using a validated protocol/order set to treat persistent hyperglycemia.[296]
If your acutely ill patient has type 1 diabetes and their blood glucose stays above 200 mg/dL (11.1 mmol/L) for more than 24 hours, check blood beta-hydroxybutyrate (or blood ketone) levels (based on expert opinion).
If your patient is being managed as an outpatient, ensure they know how often to check their blood glucose at home, whether they need to check ketones, and when to seek medical care (based on expert opinion).
When you taper the corticosteroid dose, glycemic control will likely improve, which may require gradual reduction of the dose of titrated diabetic medication back to the pre-corticosteroid regimen.[297]
If the diabetes medication is not appropriately weaned off, your patient will be at a high risk of developing hypoglycemia. Communicate the strategy for titration with the outpatient team on discharge.
The duration of action for a particular corticosteroid will determine the period of effect on glycemic control.
Intravenous corticosteroids typically have shorter half-lives, which means glycemic control returns to pre-corticosteroid levels within 24 hours.
Oral corticosteroids, especially if long acting (e.g., dexamethasone), may take a few days.
