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Steroid-Induced Hyperglycemia Case Study

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Presentation on theme: "Steroid-Induced Hyperglycemia Case Study"— 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 “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 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: Social 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: CV: Neuro:
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 Date BB AB BL AL BD AD BT Sun 76 104 98 116 Mon 112
142 129 163 Tue 125 153 176 162 Wed 132 147 155 Thu 145 166 172 143 Fri 89 272 325 409 Sat 101 332 391 412 297 375 449** 52 238 342 Ill-feeling appointment New meds

9 PE Vitals: General: 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? Hyperglycemia
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 No S/Sx of allergic reaction Causes of hyperglycemia: INITIAL illness/infection NOW Steroid effect

11 “As expected, prednisolone-treated patients with known diabetes recorded higher glucose concentrations than subjects without known diabetes. Despite receiving a variety of glucose-lowering therapies, the circadian pattern in this patient group also showed predominantly afternoon and evening hyperglycemia. In contrast to group 2, an increase in glucose after breakfast was evident in this group, and the peak glucose occurred later at approximately 2100 h, creating a staircase-like pattern. This may have arisen because of the more severe b-cell defect in subjects with known diabetes and greater impairment of postprandial insulin release.” “Because 5 of 7 subjects in group 3 recorded a glucose of at least 180 mg/dL for more than 25% of the day, patients with known DM are much more likely to benefit from additional treatment to lower blood glucose, with a greater requirement for prandial insulin with each meal. Glucose-lowering therapy should be predominantly directed at the time period between midday and midnight. Caution should be exercised with long-acting basal as it may precipitate nocturnal hypoglycemia when the effect of prednisolone wanes.” Burt et al. Hyperglycemic Effect of Glucocorticoids J Clin Endocrinol Metab, June 2011, 96(6):1789–1796

12 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)

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

14 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

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

16 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

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

18 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

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)


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