Page not availableWorsening Hyperglycemia tren prop 100 to Prednisone. Presentation A year-old woman with a 3-year history of diabetes is seen for worsening dyspnea and cough. She has had chronic obstructive pulmonary disease COPD since age She now has dyspnea with walking one-third of a block and a persistent cough. Her type 2 diabetes has been managed with diet and exercise.
Glucocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem
Worsening Hyperglycemia Due to Prednisone. Presentation A year-old woman with a 3-year history of diabetes is seen for worsening dyspnea and cough. She has had chronic obstructive pulmonary disease COPD since age She now has dyspnea with walking one-third of a block and a persistent cough. Her type 2 diabetes has been managed with diet and exercise. Her last glycosylated hemoglobin measured 1 month ago was 6.
Lungs are clear to percussion, but wheezing is present bilaterally. No accessory muscles are being used. No cyanosis is present.
Questions What is the typical pattern of steroid-induced hyperglycemia? What are reasonable treatment strategies? How can the patient's worsening COPD adversely affect her diabetes? Commentary This patient has had type 2 diabetes adequately controlled with diet for the past few years. Her blood glucose levels increased markedly with the addition of prednisone. The typical characteristics of hyperglycemia induced by corticosteroids include minimal effect on fasting blood glucose levels and an exaggeration in postprandial blood glucose elevations.
The degree of elevation is correlated with previous glucose tolerance. Patients with pre-existing diabetes can have profound increases in blood glucose. The effect of glucocorticosteroids is usually transient. In a study done by Greenstone and Shaw, 1 measuring blood glucose response to alternate day prednisone dosing, patients exhibited hyperglycemia in the afternoons of the days when the steroids were given.
Blood glucose levels normalized throughout the next day the day off of steroids. Hyperglycemia induced by glucocorticosteroids is primarily an exaggeration of postprandial hyperglycemia. Most patients will not have significantly different fasting blood glucose levels when they are receiving corticosteroids.
Glucosteroids increase hepatic glucose production and can inhibit insulin-stimulated glucose uptake in peripheral tissues.
Therapy for corticosteroid-induced hyperglycemia should target postprandial hyperglycemia. Patients with elevations of blood glucose high enough to warrant insulin therapy should receive preprandial short-acting insulin. If a patient has severe elevations of blood glucose level associated with intravenous corticosteroid administration, use of a variable-rate insulin infusion would be appropriate.
A variable-rate insulin infusion allows for rapid increase or decrease in insulin delivery depending on the dose and hyperglycemic effect of the intravenous corticosteroid.
The patient in this case has a high glucose level during the peak dose of her steroids. It is likely that her blood glucose levels will drop as she rapidly drops her prednisone dose. If she is symptomatic on the high dose of prednisone, starting an oral agent may offer some benefit. More problematic will be if she requires long-term corticosteroids. In that case, it would be appropriate to start an oral agent. Metformin Glucophage , an -glucosidase inhibitor, or a thiazolidinedione would be reasonable options.
No prospective trials are available to recommend one oral agent over another. Acarbose Precose or miglitol Glyset may be appealing options because of their actions in improving postprandial hyperglycemia. In a short case report using the a -glucosidase inhibitor voglibose not available in the United States for treatment of steroid-induced diabetes in patients with myathenia gravis, six patients were managed successfully with a decrease in urine glucose from a mean of Illnesses that require corticosteroids may worsen diabetes control.
Patients with increasing symptoms of COPD will be less likely to exercise and as a result could have an increase in weight, which would affect blood glucose control. Patients receiving corticosteroids for rheumatological disease may have lower extremity involvement, which could limit mobility and exercise. Corticosteroids also promote weight gain through increased appetite. Increased weight will lead to increased insulin resistance and failure of previously effective therapy.
Patients who are placed on corticosteroids often have additional causes for thier increase in blood glucose, such as decrease in exercise and weight gain. Alternate day corticosteroid causes alternate day hyperglycemia.
Postgrad Med J Glucosteroid-induced insulin resistance in vitro: Diabetes management in special situations. Endocrinol Metab Clin North Am Treatment of steroid-induced diabetes with alpha-glucosidase inhibitor voglibose. Eur J Neurol 5: You are invited and encouraged to send in diabetes-related case presentations from your own practice, either to illustrate a specific point of interest or to ask for advice from the experts on our editorial board about a problem in practice.
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Mail your case studies, along with a note stating your preference for the free book, to: Stacey Wages, N. Return to Issue Contents. Paauw, MD Presentation A year-old woman with a 3-year history of diabetes is seen for worsening dyspnea and cough.