Steroids and diabetes - INPATIENTS

Diabetes & endocrinology
NHS Lothian

 

*Refer all patients on insulin to diabetes team*

 

Please check baseline HbA1c in all patients starting steroids

 

 

What should I do if my patient is on steroids?

  • All patients on steroids (>20mg prednisolone or equivalent/day) should have their capillary blood glucose (CBG) checked before breakfast and evening meal (EM) or four times a day if they have pre-existing diabetes
  • Patients who have a CBG >12mmol/L should have CBG checked four times a day
  • Steroid induced or aggravated diabetes (SID) is >2 occasions of CBG >12mmol/L in a 24 hour period
  • SID will only respond to sulphonylureas (SU e.g. gliclazide) or insulin
  • CBG targets should be 6-12mmol/L (this may be higher in patients who are frail or at increased risk of hypoglycaemia)
  • The typical pattern of CBGs in SID is a normal/lower BG at breakfast that progressively increases throughout the day before falling again overnight. This means that treatment is usually given in the morning (AM) and treatment at night should be very cautious.

 

Starting a Patient on Longer term steroids? Look at additional information here

 

Patients not on insulin

Please note reduction in treatment WILL be required when steroid dose is reduced or stopped with a particular emphasis on the avoidance of hypoglycaemia. As a guide a 20% reduction in the insulin dose or 40mg reduction in gliclazide weekly as steroids are weaned is reasonable. Contact the diabetes team if there are concerns.

 

If CBG >12mmol/L (or individulalised target) start 40-80mg gliclazide in AM, or titrate morning dose if already taking gliclazide

If CBG >20mmol/L CONTACT DIABETES TEAM- MAY NEED INSULIN

Titrate gliclazide daily in increments of 40-80mg until CBG in target or on maximum of 240mg in AM

(CAUTION if eGFR <30, CONTACT DIABETES TEAM if eGFR <15)

If CBG still >12mmol/L, add in insulatard 10 units in AM and call diabetes team in hours

Patients on insulin

Please note reduction in treatment WILL be required when steroid dose is reduced or stopped with a particular emphasis on the avoidance of hypoglycaemia. As a guide a 20% reduction in the increased insulin dose weekly as steroids are weaned is reasonable. Contact the diabetes team if there are concerns.

If CBG > 12 (or modified upper target limit)

Once daily insulin

  • Change administration time of insulin to pre-breakfast and up-titrate by 10-20%/day
  • Be aware of risk of overnight hypoglycaemia
  • Contact Diabetes team if not achieving target despite titration

 

Twice daily insulin

  • Increase pre-breakfast dose by 10-20%/day to meet targets
  • Be aware of risk of overnight hypoglycaemia
  • Contact Diabetes team if not achieving target despite titration

 

Basal bolus insulin

  • Give basal insulin pre-breakfast
  • Increase bolus insulin at breakfast (and potentially lunch) by 20% 
  • Be aware of risk of overnight hypoglycaemia
  • Contact Diabetes team if not achieving target despite titration

 

For all patients, be aware that blood glucose will drop significantly overnight as steroid wears off.

Avoid over-correction late evening/overnight.

What should I do if my patient on steroids is going home?

Steroid course is complete and patient did not need any treatment for SID

  • No action is needed

Steroid course is complete and patient no longer needing treatment, but did require treatment for SID whilst an inpatient

  • Ask GP to check HbA1c in 3 months and then annually thereafter as patient at risk of developing T2DM in the future.

Patient going home on >20mg prednisolone or equivalent/day and has not needed any inpatient treatment for SID

  • Check HbA1c prior to discharge- if HbA1c is >=42 contact diabetes specialist nurses as patient may need to be taught home blood glucose monitoring and go home with a home blood glucose meter.
  • Warn patients of symptoms of hyperglycaemia* - if felt should contact GP or parent team.
    *Symptoms of hyperglycaemia-thirst, polyuria, fatigue, weight loss.
  • See outpatient steroid bundle for information and give patient information leaflet if appropriate
  • Ask GP to check HbA1c every 3 months whilst patient remains on steroids.

Patient going home on steroids and has required any inpatient treatment for SID

  • Contact the diabetes specialist nurses (DSNs) as soon as discharge date is known
  • Patient must be taught home blood glucose monitoring and hypoglycaemia management
  • Check HbA1c prior to discharge; if >=48 this is diagnostic of likely pre-existing diabetes.
  • See outpatient steroid bundle for information and give patient information leaflet if appropriate

Guidance for long term and outpatient steroid use

see long term steroid bundle