How To Address Dexamethasone-Induced Hyperglycemia for Patients with Covid-19

Dexamethasone-induced hyperglycemia is a common side effect of steroid treatment; can we reduce mortality with patients with Covid-19 by controlling blood glucose?

The factors associated with the worse outcomes of Covid-19 are older age, diabetes, hypertension, obesity, and chronic respiratory diseases. In addition, studies have shown that having diabetes and hyperglycemia upon admission to the hospital increased patient risk for mortality with COVID-19. 

Since hyperglycemia is a significant concern, we need to have blood sugar under control with patients. Dexamethasone is a long-acting steroid used to reduce inflammation in patients with Covid-19. The issue is that the main side effect of steroids is hyperglycemia, which can increase mortality with Covid-19.

The study was conducted at King Said University medical city (Saudi Arabia). A protocol was developed to manage dexamethasone-induced hyperglycemia. The study retrospectively reviewed the records and glucose levels of all adult patients with Covid-19. The study only included patients with Covid-19 that were treated with dexamethasone, and previous history of diabetes, or no diabetes but developed hyperglycemia after the initiation of dexamethasone. 

On admission, patients were screened for A1C, fasting blood glucose, order sliding scale insulin. The health care professionals implemented the protocol in determining the estimated glomerular filtration rate, weight, and age of the patient. In addition, the protocol guides healthcare professionals used to determine the assessment, titrate basal, nutritional, and correctional insulin doses. 

The study included 163 participants with Covid-19 and dexamethasone-induced hyperglycemia, of whom 116 were managed according to the protocol, and 47 were treated at the discretion of the physician following the procedures (Control group). There were no significant differences in age, sex, BMI, diabetes prevalence, nationality, etc. 

During the first five days of hospitalization and on the day of discharge for those hospitalized for longer than five days, were well-controlled between 70 and 180.  The protocol groups showcased significantly lower fasting glucose levels than the control group on the 3rd day. (135mg/dL vs 160.2 mg/dL; P<0.05), day 4 (134.1 mg/dL vs 203.4 mg/dL, respectively; P < .01), day 5 (129.6 mg/dL vs 206.1 mg/dL, respectively; P < .01) and on the day of discharge (133.2 mg/dL vs 186.3 mg/dL, respectively; P < .01)

Compared to patients in the control group, patients in the protocol group were more likely to have well-controlled glucose levels (70-180 mg/dL) across both primal and bedtime values and during the research period. Fasting glucose levels on days 4, 5, and day of discharge; Pre-lunch glucose levels on the day of discharge; pre-dinner glucose levels on days 3,5, and the day of discharge; and bedtime glucose levels on day 1 were all statistically significant (all P0.05)

In-hospital mortality in the protocol group was substantially lower than in the control group (12.93 percent vs. 29.93 percent, respectively; P = 0.01). Furthermore, patients in the protocol group were less likely to require ICU hospitalization, IV insulin infusion, or mechanical breathing than those in the control group. However, none of these changes were statistically significant. In addition, there was no statistical significance when determining the incidences of severe inpatient hypoglycemia. The protocol group did receive a slight increase in hypoglycemia but not significant enough to be an issue. 

Lastly, the protocol exam has shown that patients were managed with glucose levels 70-180 mg/dL. However, patients using the protocol had a significant mortality rate versus using the standard practice. Further studies are needed for the true relationship between continuous glucose control and mortality among patients with steroid-induced hyperglycemia versus standard care. 

Practice Pearls:

• Dexamethasone and other steroids can cause side effects such as hyperglycemia, which can increase mortality in hospitalized Covid-19 patients.
• Having an intense strategic hyperglycemia treatment showed it can reduce mortality in patients with Covid-19.
• More studies need to be done in the future to show glucose control is associated with mortality and to adopt a similar standardized protocol for patients hospitalized with Covid-19.

Asiri, A. Alguwaihes. Assessment of the effectiveness of a protocol to manage dexamethasone-induced hyperglycemia among hospitalized patients with covid-19. US national library of medicine

Idris Aderoju, Pharm.D. Candidate, Florida A&M University