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Managing Clinical Problems in Diabetes, Case Study #22: Combining Steroids and Insulin

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mr. WWB was referred to the diabetes educator by a nurse working on a medical ward. “We have a man here on the medical ward with COAD (chronic obstructive airways disease). He is in a bad way and was commenced on steroids to control the COAD. Now his blood glucose has gone very high. Can you please give him some education about diabetes and suggest how we treat him? We are giving him stat doses of Humulin R when his glucose is over 180mg/dL.(10 mmol/L), usually after lunch.”…

Diabetes educator

There are three types of steroids:
  • mineralocorticoid;
  • glucocorticoid; and
  • androgens/estrogens.

Mr. WWB was most likely prescribed a glucocorticoid, which reduces insulin release from the pancreatic beta cells at high doses, increases insulin resistance in the liver and muscle, stimulates gluconeogenesis, and increases hepatic glucose output, all of which lead to hyperglycemia. Obesity and family history of diabetes increase the risk of developing diabetes when steroids are needed. Glucocorticoids might also affect intracellular glucose transport. The diabetogenic effects may be temporary if a specific course of steroids is needed but recur if the dose is increased or steroids are used intermittently. The risk of developing glucose intolerance or diabetes with glucocorticoid use increases if there is a family history of diabetes and obesity and other diabetes risk factors are present. 

The specific steroid prescribed, the duration of the course, frequency of the dose, and treatment schedule were not provided and need to be considered when determining whether glucose-lowering medicines are indicated. However, glucose intolerance can occur within 48 hours of commencing steroids. Alternate day, interrupted dose regimes, short courses, and IV administration have less impact on blood glucose than long-term high-dose regimens. Hypertension, suppressed immune function, osteoporosis, and mood changes are other significant side effects that need to be considered and managed.

Mr. WWB’s blood glucose pattern, where the blood glucose increases over the course of the day, is not unusual. Blood glucose monitoring should be continued, probably before each meal and before bed until the blood glucose pattern stabilizes. If the steroid dose is short-term (7–14 days), twice-a-day insulin or a long-acting insulin analogue might be needed. If long-term steroids are indicated, oral glucose-lowering agents might be effective if there are no contraindications to their use. Top doses of insulin are not recommended. They are reactive and only partially correct the blood glucose. 

If Mr. WWB is discharged on steroids he will need careful education about how to manage his steroids, including managing his glucose lowering medicines if the steroid dose is increased or reduced. He will need to learn blood glucose testing, safe sharps disposal, how and where to obtain his diabetic supplies, and should carry a card indicating he has diabetes and that he is on steroid medicines. He should be advised to have relevant immunizations to prevent inter-current infections such as influenza, and a complication assessment, and may benefit from a dietetic review.

Atypical antipsychotic medicines are also associated with hyperglycaemia and diabetes (Guo et al. 2006).

Health assessment, management targets, and deciding on a management plan

Key points

  • Individualized holistic assessment is essential to planning appropriate care for people with diabetes.
  • Mental, spiritual, and general health status should be monitored as assiduously as diabetes status.
  • The individual must be involved in planning and monitoring his or her care.
  • Collaborative, structured multidisciplinary team care is essential to achieving optimal outcomes and continuity of care.

References

Borch-Johnsen K, Wenzel H, Vibert G et al. (1993) Is screening and intervention for microalbuminuria worthwhile in patients with IDDM? British Medical Journal 306: 1722–1725.

Boulware LE, Marinopoulos S, Phillips KA et al. (2007) Systematic review. The value of the periodic health examination. Annals of Internal Medicine 146: 289–300.

Cohen M (1996) Diabetes: A Handbook of Management.International Diabetes Institute, Melbourne.

Del Prato S (2002) In search of normoglycaemia in diabetes: controlling postprandial glucose. International Journal of Obesity 26:s 9–17.

Del Prato S, Tiengo A (2001) The importance of first-phase insulin secretion: implications for the therapy of type 2 diabetes. Diabetes Metabolism Research Review 17: 164–174.

Natrass M (2002) Improving results from home blood-glucose monitoring:accuracy and reliability require greater patient education as well as improved technology. Clinical Chemistry 48: 979–980.

Oates D, Berlowitz D, Glickman M et al. (2007) Blood pressure survival in the oldest old. Journal of the American Geriatrics Society 55(3): 383–388.

Surgeon General’s Report (2006) The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General – Executive Summary. US Department of Health and Human Services, Centre for Disease Control and Prevention, Office of Smoking and Health. UK Prospective Diabetes Study Group (1998) Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. UKPDS 33. Lancet 52: 837–853.

Recommended reading

Abrahamson M (2004) Optimal glycaemic control in type 2 diabetes mellitus. Fasting postprandial context. Archives of Internal Medicine 164: 486–491.

Australian Medicines Handbook (2006) National Prescribing Service, Adelaide.

Bergenstal RM, Gavin JR (2005) The role of blood glucose selfmonitoring in the care of people with diabetes: report of a global consensus conference. American Journal of Medicine 118(9a): 1S–6S.

British Diabetes Association (1999) Guidelines for Practice for Residents with Diabetes in Care Homes. Diabetes UK, London.

Diabetes Control and Complications Trial (DCCT) Research Group (1993) Effects of intensive insulin therapy on the development and progression of long-term complications of IDDM. New England Journal of Medicine 329: 977–986.

Dunning T (2003) Care of People with Diabetes: A Manual of Nursing Practice. Blackwell Publishing, Oxford.

Dunning T (2005) Nursing Care of Older People with Diabetes.Blackwell Publishing, Oxford.

National Heart Foundation (2001) Lipid Management Guidelines. National Heart Foundation, Melbourne. UK Prospective Study Group (1998) Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. UKPDS 33. Lancet 52: 837–853.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion #23

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath