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Steroids and Diabetes

Steroids and Diabetes. Caroline Brooks DISN Maidstone & Tunbridge Wells NHS Trust. Aims. To be interactive & share clinical experience & practice (maybe have fun?) Explore the breadth & depth of our knowledge of types of steroids and conditions they are used for.

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Steroids and Diabetes

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  1. Steroids and Diabetes Caroline Brooks DISN Maidstone & Tunbridge Wells NHS Trust

  2. Aims • To be interactive & share clinical experience & practice (maybe have fun?) • Explore the breadth & depth of our knowledge of types of steroids and conditions they are used for. • To familiarise ourselves with the JBDS guidelines • Discuss management options for stabilising steroid induced hyperglycaemia in given scenarios

  3. 2 minute preparatory activities for a Quiz;0n each table: • Team name: 2-3 people on your table to create a team name using as many letters as possible from the initials of each person on your table • Write that name on the score chart at the front of the room (points for speed and ingenuity) • Sort your “buzzer”: 1 person to find a ring tone on their phone which will become your “buzzer” • 4 people to choose a paper plate with a letter on it • Choose 1 person to be the writer (quick and neat) • Choose 1 person to be the caller

  4. Steroids

  5. Steroid Induced Diabetes Natural Cortisol: Diabetes Because: • Mobilises nutrients • Helps fight Inflammation • Regulates fluid balance & BP • Assists with memory function • Moderates a response to stress (Fight/fright/flight) • Stimulates Gluconeogenesis • Liver raises circulating glucose levels • Cortisol creates an Insulin resistant state • Leads to overproduction of Insulin and pancreatic Beta cell decline

  6. Name the 3 other “Gluco-counter-regulatory” hormones : Find your Buzzers….. Epinephrine (Adrenalin) Glucagon Growth Hormone

  7. Route of Administration Are topical or inhaled steroids likely to affect blood glucose levels? Are intra-articular injections of steroids likely to affect blood glucose levels? Topical: Not a known side effect Inhaled: Only at very high doses A documented side effect “ likely for several days”

  8. For 1 minute:List the types of systemic Steroids you have encountered in clinical practice Oral/injection Topical/Injection/Inhaled • Betamethasone (congenital adrenal hyperplasia) • Budesonide (auto-immune hepatic disease) • Deflazacort(derived from Prednisolone) • Dexamethasone • Fludrocortisone (mineral corticoid) • Hydrocortisone • Methylprednisone • Prednisolone • Triamcinolone Acetonide(IM or intra-articular injection) • Alclomethasone-topical • Beclomethasone-Inhaled/topical/nasal • Budesonide(topical, inhaled, rectal/nasal) • Ciclesonide(inhaled) • Clobetasolpropionate (Dermovate) • FluocinaloneAcetonide (eyes/topical) • Fluticasone (inhaled) • Triamcinolone Acetonide (nasal or inj)

  9. As a team in 2 minutes:List all the conditions that may be treated with (cortico) steroids

  10. A-Z of Cortico-steroid uses • Asthma • Allergies • Auto immune conditions • Back & Joint pain • Brain Tumour • Cancer • Congenital adrenal hyperplasia • COPD • Crohns • Dexamethasone suppression test • End stage renal failure • Excema • Glomerulonephritis • Idiopathic thrombocytopenic purpura • Inflammatory Bowel disease • Multiple Sclerosis • Myasthenia Gravis • Leukaemia • Lupus • Lymphoma • Pemphigoid • Pre-term labour • Postural Hypotension • Psoriasis • Replacement therapy • Rheumatoid Arthritis • Skin Rashes • Temporal Arteritis • Tendinitis • Transplant • Uveitis • Vasculitis

  11. Holding up the plates provided :Place these (dose/strength equivalent) steroids in order of duration of action • Dexamethasone 0.75mg • Hydrocortisone 20mg • Methylprednisolone 4mg • Prednisolone 5mg B. Hydrocortisone 8hrs D. Prednisolone 16-36hrs C. Methylprednisolone 18-40hrs A.Dexamethasone 36-54hrs N.B. potency relates to anti-inflammatory action, which may not equate to hyperglycaemic effect Source: JBDS Guidelines

  12. Steroid Type/Dose Strength Equivalents and duration of action Equivalent doses (Half-life in hours) • Hydrocortisone 20mg 8 hours • Prednisolone 5mg 16-36hrs • Methylprednisolone 4mg 18-40hrs • Dexamethasone 0.75mg 36-54hrs • Betamethasone 0.75mg 26-54hrs • N.B. potency relates to anti-inflammatory action, which may not equate to hyperglycaemic effect

  13. Profile of Capillary Blood Glucose (CBG) Profile with Prednisolone Does it Matter?

  14. Australian study: WahCheung N. Steroid-induced hyperglycaemia in hospitalised patients: does it matter? Diabetologia 2016 59:2507–2509 • 785 patients with Community Aquired Pneumonia (CAP) • Randomised to receive 50mg prednisolone or placebo • Prednisolone treated group recovered more quickly • In the steroid treated group, 50% of non-diabetic and 88% of those with diabetes those developed hyperglycaemia • But hyperglycaemia was not associated with a delayed recovery • Author questions the importance of BG control in this group

  15. Hold up the correct plate (A/B/C/D):According to JBDS Steroid guidelines: The likely percentage of inpatients on steroids: Respiratory patients account for what percentage of steroid takers? • 3% • 8% • 10% • 16% • 15% • 20% • 30% • 40%

  16. Quick “plate” QUIZZ- Continued What is the percentage incidence of hyperglycaemia in patients taking steroids? For type 1 diabetes,JBDS Steroid guidelines indicate that insulin may need to increase by as much as: • 25% • 30% • 40% • 65% • 1% • 12% • 25% • 50% We don’t Know! Alabbood et Al-Recent Literature review Variation between 1-50% Multiple small scale studies Variable conditions and variable steroids Didn’t consider underlying predisposition

  17. Quick QUIZZ- “Buzzers” ready!JBDS guidelines recommendations: • Patients on steroids should have CBG checked at what time? • Pre/Post lunch and/or eve meal • What BG level should trigger intervention? • 12mmols/L • What’s the first line treatment for steroid induced diabetes? • Gliclazide (or isophane insulin) • What is the maximum recommended am dose of Gliclazide? • 240mg • What is the maximum recommended total daily dose? • 320mg

  18. Known Diabetes: Monitoring Patients on Steroids: Not known to have diabetes: • Check HbA1c in patients predisposed to diabetes • Monitor Daily-Pre/post lunch or Evening meal • IF BG >12 – Increase monitoring to QDS • IF Pre meal/Pre bed BG repeatedly > 12 start active management • Monitor QDS, pre meal/pre bed • IF Pre meal/Pre bed BG repeatedly > 12 start active management

  19. Withdrawing Systemic Corticosteroids • Withdrawal determinedon a case-by–case basis considering : • the underlying condition that is being treated, and individual • the likelihood of relapse • the duration of corticosteroid treatment.  • Gradual withdrawal of steroids should be considered in those whose disease is unlikely to relapse &have: • received more than 40 mg prednisolone (or equivalent) daily for more than 1 week; • been given repeat doses in the evening; • received more than 3 weeks’ treatment; • recently received repeated courses (particularly if taken for longer than 3 weeks); • taken a short course within 1 year of stopping long-term therapy; • other possible causes of adrenal suppression. • Systemic corticosteroids may be stopped abruptly in those: • whose disease is unlikely to relapse  • and who have received treatment for 3 weeks or less  • and who are not included in the patient groups described above.https://bnf.nice.org.uk

  20. Challenging Cases • Discuss the case summary and information provided for 5-10 minutes • Key points on flip chart paper • Present for 5 minutes (max)

  21. Case scenario: Gita Gita is a 76 yr old lady with type 2 diabetes on Metformin (liquid). She has a tumour in her neck, which affects her swallowing. (soft diet) Receiving palliative DXT & Dexamethasone 4mg OM for symptom control. She is started on Gliclazide 80mg am with steroids, achieving : CBG: 6-9 fasting 10-15 pre lunch, 12-18 evening, quite variable BG according to diet supplements. On Saturday her DXT finishes, so steroids can usually be weaned, On Monday DSN is informed Gita will have a PET scan on Thursday at 11.30 am. CBG must be stable between 4-12 for scan. Oncologist decides to reduce Dexamethasone 4mg to alternate daily, rather than reducing the daily dose. What would you do to optimise control given the therapy constraints, preparation & CBG targets for a PET scan? (see PET scan guidelines)

  22. Local PET CT scan guidelines for people with diabetes • Tablets: To have food and medication 6 hours before scan, then fast (drink water 1-2 pints)no sweets! • AM scan: Omit diabetes tablets & fast (bring meds & lunch) • PM scan: Take am tablets then fast for 6 hrs • Insulin short acting: Food and medication 4 hours before scan then fast (drink water 1-2 pints) no sweets! • Call the PET scan booking team if feeling hypo! • Stable diabetes control 4-12.5 mmols/L-otherwise scan is cancelled • Inform PET scan team if taking corticosteroids

  23. PET Scans and Glycaemic management> 60 hospitals have access to PET CT scanners • An (FDG) PET scan is a medical imaging technique that produces a 3-D image of functional processes in the body. • Asmall amount of a radioactive drug“tracer” (FDG) is injected before the scan to show differences between healthy tissue and diseased tissue. • Cancer cells absorb more of the FDG which shows up in scan. • Glucose and insulin compete with and inhibit cell uptake & distribution of FDG, affecting scan results • Careful regulation of diet, activity, and medication is required prior to scan Steroids potentially increase the risk of failure to meet glycaemic standards required

  24. PET scans and glycaemic management:Reference: Surasi et al F-PET/CT Patient Preparation Protocol: A review of the Literature. Journal of Nuclear Med technology 2014; 42:5-13 General recommendations: • Serum insulin at basal levels • No IV dextrose • High protein, low CHO diet 24 hours prior to scan • Coordinate use of steroids with scheduled scan • Home glucose monitoring-BG ideally between 8-11 • Hold Metformin for GI tumours • Schedule scan at a time to best meet glycaemic medication requirements, e.g 7am, or midday • IV insulin up to 90mins prior to tracer FDG injection

  25. Case scenario: Peter Peter age 66 yrs, lives with his wife, has known Type 1 diabetes, DAFNE Graduate;  HbA1c 56 Levemir 10 units BD, Novorapid variable Recent diagnosis Inoperable Brain Tumour Increasing confusion, but determined to remain independent Commenced Dexamethasone 8mg at 8am and 14:00hrs CBG 18mmols/L – “HI” How would you manage the likely issues raised in this situation?

  26. Likely issues with Peter’s Type 1 diabetes Blood Glucose control Locus of “self control”

  27. Case Scenario: Kenneth Kenneth is 74 years old, lives with his cousin David, who is his main carer. Ken has a memory problemand poor mobility. Not known to have diabetes. Admitted with Bullous Pemphigoid blisters. Commences 30 mg Prednisolone and develops hyperglycaemia CBG profile: Fasting 4.1-5, pre-lunch 11-14, Eve meal 15-18, Bed: 10-14 Gliclazide 40 mg commenced at 8am and midday, but CBG Fasting 3.4-4.1, pre lunch2.9-3.8, Eve meal 14-17, Bed 11-15 Likely discharge soon, with weaning prednisolone by 5mg weekly. What would your management plan be?

  28. Case Scenario: Kenneth

  29. Case Scenario: Kenneth

  30. Personal tips • Simplify-Keep regimes simple for short term management • Try to rely on the meds that the patient is familiar with: • E.g. If on a BD mix, try adding in a lunch dose, or moving the evening dose to lunchtime to cover steroids rather than changing to something different • End Goal:-Consider the importance/relevance of tight control • Record-for patients on & off steroids –tabulate what worked for that individual to refer to next time • Overlay-try adding in an isophane insulin (if licensed) over usual meds-makes for easy withdrawal • Inform the steroid prescriber that its affecting the blood glucose levels • Differentiate very clearly to patient & HCP’s what meds are covering steroids and what’s for usual diabetes management • Symptom controlc.brooks@nhs.net

  31. References/useful articles • Alabbood M, et al. Glucocorticoid-induced diabetes among people without diabetes: a literature review. Practical Diabetes 2018; 35(2):63-67 • https://bnf.nice.org.uk • JBDS-IP guidelines: Management of hyperglycaemia and (glucocorticoid) steroid therapy 2014 • Kempegowda P, et al. Are they high on Steroids? Tailored interventions help improve screening for steroid-induced hyperglycaemia in hospitalised patients. BMJ Open Qual. 2018; 7(1): e000238. • WahCheung N. Steroid-induced hyperglycaemia in hospitalised patients: does it matter?Diabetologia2016 59:2507–2509

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