Glucocorticoid-Induced Hyperglycemia Management

Introduction to Glucocorticoid Effects

• Glucocorticoids induce hyperglycemia in patients with and without antecedent diabetes, according to the American Diabetes Association guidelines 1, 2

Insulin Adjustment Considerations

• For long-acting glucocorticoids like dexamethasone, long-acting insulin adjustments are necessary, with significant increases in basal insulin required to control fasting blood glucose, as recommended by the American Diabetes Association guidelines 1, 3
• Higher doses of prandial and correction insulin (40-60% or more) are often needed in addition to increased basal insulin, as suggested by the American Diabetes Association 3
• Insulin therapy is indicated when HbA1c ≥10% or blood glucose ≥300 mg/dL, patient has symptoms of hyperglycemia, evidence of catabolism, or oral medications fail to achieve glycemic targets, as recommended by the American Diabetes Association 4, 5

Insulin Initiation and Titration

• The American Diabetes Association recommends a preferred initial regimen of basal insulin (long-acting) once daily plus oral medications, with long-acting options including insulin glargine, detemir, or degludec 4
• For insulin-naïve patients, start with 10 units once daily with the largest meal, as recommended by the American College of Physicians, based on evidence from the Annals of Internal Medicine 6
• Adjust dose by 2-4 units once or twice weekly based on fasting blood glucose levels, according to the American Diabetes Association, with moderate-strength evidence 6
• Increase dose by 2 units every 3 days until fasting glucose target is reached without hypoglycemia, as recommended by the American Diabetes Association 7, 8, 9, 10

Blood Glucose Monitoring and Action

• The following table outlines the recommended actions for different blood glucose levels:

• Blood glucose should be checked before breakfast daily during titration, and additional checks before lunch and dinner may be considered to assess 24-hour control, as recommended by the American Diabetes Association 9

Hypoglycemia Management

• The American Diabetes Association recommends treating hypoglycemia with 15-20g of glucose, and rechecking blood glucose after 15 minutes and repeating treatment if still low, and educating patients on hypoglycemia recognition and management, and always carrying a source of quick-acting carbohydrates 12, 7
• Prescribe glucagon for emergency hypoglycemia management, as recommended by the American Diabetes Association 8
• There is an increased risk of hypoglycemia with higher insulin doses, especially in patients with renal impairment or irregular eating patterns, according to the American Diabetes Association 3

Special Considerations

• Patients on glucocorticoids may need higher insulin doses, with 75% allocated to prandial insulin and 25% to basal insulin, as suggested by the American Diabetes Association 13
• For patients with pre-existing diabetes, the distribution of insulin should shift to approximately 25% basal and 75% prandial while on dexamethasone 13
• For hospitalized patients with diabetes, critical care involves continuous intravenous insulin infusion with a target glucose of 140-180 mg/dL, while non-critical care involves scheduled subcutaneous insulin with basal, nutritional, and correction components, and avoiding sliding scale insulin alone as sole therapy is recommended, as stated by the American Diabetes Association 14, 13

Lifestyle and Additional Interventions

• Encourage physical activity, aiming for 150 min/week of moderate-to-vigorous activity, as recommended by the American Diabetes Association 15
• Targeting fasting glucose levels of 90-150 mg/dL for older adults, and less stringent HbA1c goals (such as <8%) for patients with limited life expectancy or extensive comorbidities, are recommended by the American Diabetes Association 9, 16
• Consider combination with metformin or SGLT-2 inhibitors to minimize weight gain, and continue to reinforce behavioral interventions that contributed to weight loss, as recommended by the American Diabetes Association 5, 8

Medication Considerations

• The use of sulfonylureas during dexamethasone therapy is not recommended due to an increased risk of hypoglycemia 13
• Consider discontinuing sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists on an individual basis, as suggested by the European Association for the Study of Diabetes, with low-strength evidence 6
• Continue metformin when initiating Ryzodeg if not contraindicated, as recommended by the American Association of Clinical Endocrinologists, with moderate-strength evidence 6

Discontinuation of Dexamethasone

• When dexamethasone is discontinued, insulin requirements can decline rapidly, requiring close monitoring and potential reduction of the Lantus dose to avoid hypoglycemia, as recommended by the American Diabetes Association 13