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Steroid-Induced Hyperglycemia Case Study

Steroid-Induced Hyperglycemia Case Study. Lucia M. Novak, MSN, ANP-BC, BC-ADM The Diabetes Institute Walter Reed Army Medical Center, Washington, DC Adjunct Assistant Professor, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD.

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Steroid-Induced Hyperglycemia Case Study

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  1. Steroid-Induced HyperglycemiaCase Study Lucia M. Novak, MSN, ANP-BC, BC-ADM The Diabetes Institute Walter Reed Army Medical Center, Washington, DC Adjunct Assistant Professor, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD

  2. Steroid-induced Hyperglycemia Case Study~Betty~ 67 yo Caucasian woman Presents with complaint of “very high” glucose readings for the last 3 days Last appointment 4 days ago for URI with hx of COPD Last wellness appointment was 1 month ago Up until she became ill, her diabetes was “well controlled.” She states that her blood sugars began to trend higher than usual when she 1st became sick, however she believes she is having an allergic reaction to her medicationsbecause they have never been as high as they are now “not even when I was initially diagnosed with diabetes.”

  3. Pertinent History • Past Medical History: • Type 2 Diabetes Mellitus (3 years) • Hypertension (10 years) • Dyslipidemia (3 years) • Chronic Obstructive Pulmonary Disease (5 years) • Social History: • Married • Retired accountant • Former smoker, quit 10 years ago • 1 glass of wine with dinner • Allergies: NKDA

  4. Current DM Management • Medications: • Metformin (Glucophage XR ) 2000 mg once daily (2008) • Glipizide (Glucotrol XL) 10 mg once daily (2009)

  5. Other medications • ECASA 81 mg • Statin for cholesterol • ACE-I for blood pressure • Diuretic for blood pressure • Albuterol MDI 2 puffs as needed every 4-6 hours • Advair every 12 hours • **Augmentin 875 mg twice daily for 10 days • **Prednisone Taper over 14 days • 60 mg x3, then 40 mg x3, then 20 mg x3, then 10 mg x3, then 5 mg x2 • OTC • Acetaminophen as needed • **= RECENTLY PRESCRIBED MEDICATIONS

  6. Review of Systems • General: • Feels fatigued, fever and chills resolved by day 2 of new meds • CV: • Denies CP, SOB, DOE, postural dizziness • Neuro: • intermittent tingling and burning to both feet x 2 days • GU: +polyuria and nocturia 1-2x nightly x 3 days • Skin: denies rash, pruritus

  7. Latest labs values (1 month ago) • A1C: 6.3% • Fasting Glucose: 103 mg/dL • Scr: 1.3 mg/dL • GFR: >60 mL/min • AST: 32 U/L • ALT: 24 U/L • Microalb/creatinine: 10.6 mg/g CRT • LDL-C: 86 mg/dL • TG: 132 mg/dL

  8. Blood sugar record Ill-feeling appointment New meds

  9. PE • Vitals: • B/P: 124/62, HR: 98 reg • Temp: 99.1’ F • Ht: 67” Wt: 142 lbs BMI: 22.2 kg/m² • General: • Well-nourished, well-developed, ill-appearing, Cauc woman, A&Ox4, NAD

  10. What are YOUR concerns? • Allergic reaction? • reassurance • Hyperglycemia • Cause(s)? • What is the typical pattern of steroid-induced hyperglycemia? • Minimal effect on fasting glucose, often are normal • Exaggeration of postprandial glucose that will lead to elevated BGs all day • Degree of elevation correlates with previous glucose tolerance, worse for those with pre-existing DM • TRANSIENT • blood glucose will drop as steroid dose reduced • return to baseline once steroid stopped if no GLUCOTOXICITY

  11. Treatment Strategies • If diet/exercise controlled: • add metformin or SFU or both • If already taking medication for DM, will likely need insulin ADDED • Basal: • NPH Vs. long-acting analog (Lantus or Levemir)

  12. s.c. injection Basal Insulin Replacement Therapy Normal Insulin Secretion at Meal Time Insulin Glargine/Detemir NPH Insulin Change in Serum insulin Time (hours)

  13. Treatment Strategies • If diet/exercise controlled • add metformin or SFU or both • If already taking medications for DM, will likely need insulin ADDED • Basal: NPH Vs. long-acting (Lantus or Levemir) • Prandial: analog Vs. Regular

  14. s.c. injection Bolus Insulin Replacement Therapy Normal Insulin Secretion at Meal Time Rapid-acting Analog Regular insulin Change in Serum insulin Time (hours) Apidra Humalog Novolog

  15. Treatment Strategies • If diet/exercise controlled • add metformin or SFU or both • If already taking medications for DM, will likely need insulin ADDED • Basal: NPH Vs. long-acting (Lantus or Levemir) • Prandial: analog Vs. Regular • Pre-Mixed

  16. s.c. injection Mixed Insulin Replacement Therapy Normal Insulin Secretion at Meal Time Analog Mix PreMix 70/30 (NPH/REG) Change in Serum insulin Time (hours) 75/25 Humalog Mix 70/30 Novolog Mix

  17. Treatment Strategies • If diet/exercise controlled • add metformin or SFU or both • If already taking medications for DM, will likely need insulin ADDED • Basal: NPH Vs. long-acting (Lantus or Levemir) • Prandial: analog Vs. Regular • Pre-Mixed • Do nothing and wait it out? • Glucotoxicity • Dehydration • HHS/DKA

  18. What do I do TODAY? Continue metformin Hold the SFU Start NPH in AM with prednisone dose Add either REG or analog before meals Reduce insulin doses by 10-20% with each reduction of steroid dose Consider IV rehydration (1 liter NS) and push oral fluids (non-caloric)

  19. Other steroids: Decadron and CSI • How would you expect blood sugar pattern to look? • How might this affect your treatment options? • NPH or analog basal (Lantus or Levemir)

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