Managing Insulin Therapy in Patients on Steroids

Introduction to Steroid-Induced Hyperglycemia

The American Diabetes Association recommends converting to a twice-daily NPH insulin regimen with morning-weighted dosing for patients on prednisone who do not want to carb count, rather than discontinuing prandial insulin completely 1, 2
Morning dosing of NPH insulin is particularly appropriate for steroid-induced hyperglycemia due to its peak action at 4-6 hours, which aligns with the hyperglycemic effect of prednisone 3
Patients on once-daily steroids like prednisone typically experience disproportionate hyperglycemia during the day but may reach target glucose levels overnight regardless of treatment 3

Calculate total daily insulin needs and convert to twice-daily NPH with morning-weighted dosing, where total NPH dose is approximately 80% of current total daily insulin dose 1, 2, 3
The morning dose should be 2/3 of the total NPH dose, and the evening dose should be 1/3 of the total NPH dose 1, 2
Titrate NPH doses based on glucose patterns, increasing the morning dose if daytime hyperglycemia persists 3

Complete discontinuation of prandial insulin is not recommended, as NPH alone may not adequately cover mealtime glucose excursions, especially with high-dose prednisone 3, 4
Patients on steroids often require 40-60% higher insulin doses than their usual requirements 3
The insulin-to-steroid ratio is important, with higher ratios improving time in range but may increase hypoglycemia risk 3

If twice-daily NPH proves insufficient, consider a self-mixed/split insulin regimen with NPH and rapid-acting insulin or progress to a full basal-bolus regimen if necessary 1, 2
For patients with persistent nocturnal hypoglycemia on NPH, consider switching to a long-acting basal analog with separate fixed prandial dosing 2