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Steroid-Induced Hyperglycemia Case Study Lucia M. Novak, MSN, ANP-BC, BC-ADM The Diabetes Institute Walter Reed Army Medical Center, Washington, DC Adjunct.

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Presentation on theme: "Steroid-Induced Hyperglycemia Case Study Lucia M. Novak, MSN, ANP-BC, BC-ADM The Diabetes Institute Walter Reed Army Medical Center, Washington, DC Adjunct."— Presentation transcript:

1 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

2 Steroid-induced Hyperglycemia Case Study ~Betty~  67 yo Caucasian woman  Presents with complaint of readings for the  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 1 st became sick, however she believes she is having an because they have never been as high as they are now “not even when I was initially diagnosed with diabetes.”  She states that her blood sugars began to trend higher than usual when she 1 st became sick, however she believes she is having an allergic reaction to her medications because 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) Type 2 Diabetes Mellitus (3 years) Hypertension (10 years) Hypertension (10 years) Dyslipidemia (3 years) Dyslipidemia (3 years) Chronic Obstructive Pulmonary Disease (5 years) Chronic Obstructive Pulmonary Disease (5 years)  Social History: Married Married Retired accountant Retired accountant Former smoker, quit 10 years ago Former smoker, quit 10 years ago 1 glass of wine with dinner 1 glass of wine with dinner  Allergies: NKDA

4 Current DM Management  Medications: Metformin (Glucophage XR ) 2000 mg once daily (2008) Metformin (Glucophage XR ) 2000 mg once daily (2008) Glipizide (Glucotrol XL) 10 mg once daily (2009) 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 Acetaminophen as needed  **= RECENTLY PRESCRIBED MEDICATIONS

6 Review of Systems  General: Feels fatigued, fever and chills resolved by day 2 of new meds Feels fatigued, fever and chills resolved by day 2 of new meds  CV: Denies CP, SOB, DOE, postural dizziness Denies CP, SOB, DOE, postural dizziness  Neuro: intermittent tingling and burning to both feet x 2 days 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 DateBBABBLALBDADBT Sun Mon Tue Wed Thu Fri Sat Sun ** Mon Ill-feeling appointment New meds

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

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

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

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

14 Treatment Strategies  If diet/exercise controlled add metformin or SFU or both 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) Basal: NPH Vs. long-acting (Lantus or Levemir) Prandial: analog Vs. Regular Prandial: analog Vs. Regular

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

16 Treatment Strategies  If diet/exercise controlled add metformin or SFU or both 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) Basal: NPH Vs. long-acting (Lantus or Levemir) Prandial: analog Vs. Regular Prandial: analog Vs. Regular Pre-Mixed Pre-Mixed

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

18 Treatment Strategies  If diet/exercise controlled add metformin or SFU or both 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) Basal: NPH Vs. long-acting (Lantus or Levemir) Prandial: analog Vs. Regular Prandial: analog Vs. Regular Pre-Mixed Pre-Mixed  Do nothing and wait it out? Glucotoxicity Glucotoxicity Dehydration Dehydration HHS/DKA HHS/DKA

19 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)

20 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) NPH or analog basal (Lantus or Levemir)


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