Insulin Adjustments for Patients with Diabetes Starting Prednisone

Understanding Prednisone's Effect on Blood Glucose

Prednisone reaches peak plasma levels in 4-6 hours after administration but has pharmacologic actions that last throughout the day, affecting patients with diabetes 2
The typical glycemic pattern for patients on morning prednisone shows normal or mild fasting hyperglycemia, with increasing hyperglycemia during the afternoon, peaking in the evening, in patients with diabetes 3
Patients on morning steroid regimens have disproportionate hyperglycemia during the day but frequently reach normal blood glucose levels overnight, according to the American Diabetes Association 2

For patients already on insulin, the American College of Endocrinology recommends increasing total daily insulin dose by 30-50% during steroid treatment to manage steroid-induced hyperglycemia 4
NPH insulin is particularly effective due to its peak action profile that aligns with the peak hyperglycemic effect of glucocorticoids, as recommended by the American Association of Clinical Endocrinologists 1
For patients on high-dose glucocorticoids, insulin requirements may increase by 40-60%, according to the American Diabetes Association 5, 1

For patients not previously on insulin, the American College of Endocrinology recommends starting NPH at 0.1-0.2 units/kg per day administered in the morning to manage steroid-induced hyperglycemia 1

The American Association of Clinical Endocrinologists recommends monitoring blood glucose 4 times daily during steroid therapy, with special attention to afternoon and evening values, to manage steroid-induced hyperglycemia 4
For persistent hyperglycemia, the American College of Endocrinology recommends increasing NPH dose by 2 units every 3 days until target blood glucose is achieved 1
If hypoglycemia occurs, the American Association of Clinical Endocrinologists recommends reducing NPH dose by 10-20% to manage steroid-induced hypoglycemia 1

For patients receiving enteral/parenteral nutrition while on steroids, the American Diabetes Association recommends that NPH insulin can be administered two or three times daily (every 8 or 12 hours) to manage steroid-induced hyperglycemia 2, 3
For long-acting glucocorticoids such as dexamethasone, the American College of Endocrinology recommends that long-acting basal insulin may be required instead of NPH to manage steroid-induced hyperglycemia 5, 2
Insulin requirements typically decrease rapidly after steroid discontinuation, requiring prompt dose adjustments to avoid hypoglycemia, according to the American Association of Clinical Endocrinologists 4
The American Diabetes Association recommends that sulfonylureas are not recommended for managing steroid-induced hyperglycemia due to risk of prolonged hypoglycemia 4