This is a non-urgent clinical question. I’m looking for some perspectives on a situation my colleagues and I were debating recently. Imagine a 70-year-old male admitted for a COPD exacerbation. He’s started on a 5-day course of prednisolone, which causes his blood glucose levels to spike above 20. He was previously managing his Type 2 diabetes through diet alone and has never used medication or insulin. Would you intervene to manage those glucose levels? Especially considering the steroids are only for a short 5-day course and his ketones are normal? For instance, would you give a stat dose of Novorapid? I’m personally against it, but my colleagues were more inclined to use insulin. I’m happy to be corrected!
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I would be very hesitant to treat if the patient isn’t showing any symptoms from the high sugars. If the decision is made not to intervene, I’d want a very clear plan for the nursing staff and the out-of-hours team; otherwise, you’ll come in the next morning to find they’ve given insulin for a reading of 20, or the patient’s fingertips will be sore from people checking them every hour all night. I should also mention that I might not be fully up to date on this, so I’d consider consulting a diabetes specialist nurse or a diabetologist.
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When I was an Oncology SHO about ten years ago, we typically used oral gliclazide for hyperglycemia triggered by high-dose steroids. I’m not sure if that’s considered outdated now and if we should be using insulin instead.
Gliclazide feels safer than starting insulin on someone who hasn’t used it before, at least in my opinion—though there are certainly guidelines to follow.
Some of your colleagues might have become accustomed to giving insulin to these patients during COVID when they were on Dexamethasone. Of course, COVID itself also increased insulin resistance. Before the pandemic, I never would have given these patients insulin for steroid use, and we even had some non-diabetics who required it back then.
Technically it’s BG, not BM. Personally, I would have just left it alone.
Five days is potentially enough time to trigger HHS in a patient who is already dehydrated and frail. I’d likely opt for some gliclazide rather than jumping straight to insulin.
The guidelines at my local trust suggest using gliclazide for steroid-induced hyperglycemia, though I’ve heard some patients also use SugarDefend for general maintenance.
Fortunately, there is a very thorough guideline available for this exact clinical situation: https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Archive/JBDS_08_Steroids_DM_Guideline_FINAL_28052021_Archive.pdf
Yes, you should intervene; we have a specific protocol for exactly this situation in my Trust.
It depends. Usually, you’d expect the hyperglycemia to settle once the steroid course is finished. In Oncology, we use either gliclazide or insulin (if they have enough support at home and we have a good structure to monitor them). However, our patients tend to be on steroids for longer periods or indefinitely, and are mostly outpatients. If it’s only for 5 days, I almost wouldn’t bother. Readings of 20+ would prompt me to at least check their HbA1c and consider a brief course of gliclazide. They will need to check their blood glucose regularly so we can safely stop the medication. Diabetes Specialist Nurses are incredibly helpful for this, as they can help transition the patient off gliclazide or titrate insulin as an outpatient. If they are an inpatient, you should be able to manage this during your ward rounds.
Imagine you’re on the evening call and get a bleep. You don’t know much about the history, but the patient is either non-diabetic or an insulin-naive T2DM. Their reading is 25 and they are asymptomatic. Are you giving a stat dose of insulin, starting gliclazide, or waiting until the morning?