What is Steroid-Induced Hyperglycemia?

Steroid-Induced Hyperglycemia (also called Steroid Diabetes or Glucocorticoid-Induced Diabetes) is elevated blood sugar caused by glucocorticoid medications (e.g., prednisone, dexamethasone, hydrocortisone). It can occur in patients with or without pre-existing diabetes.

Common Glucocorticoid Medications:

• Prednisone, Prednisolone
• Methylprednisolone (Medrol®)
• Dexamethasone (Decadron®)
• Hydrocortisone
• Triamcinolone, Betamethasone

How Common is it?

• Affects 20-50% of patients on moderate to high-dose steroids
• Risk increases with higher doses and longer duration
• More common in patients with risk factors for diabetes (obesity, family history, prediabetes)

How Do Steroids Raise Blood Sugar?

Glucocorticoids oppose insulin action and increase glucose production:

• Increase Insulin Resistance: Cells become less responsive to insulin
• Increase Hepatic Glucose Production: Liver makes more glucose (gluconeogenesis)
• Decrease Glucose Uptake: Muscles and fat take up less glucose
• Impair Insulin Secretion: Pancreas may produce less insulin over time
• Result: High blood sugar, especially after meals

Timing of Hyperglycemia:

• Peak Effect: Afternoon/evening (4-12 hours after morning steroid dose)
• Fasting Glucose: Often normal or mildly elevated
• Postprandial (After-Meal) Glucose: Markedly elevated
• Timing depends on steroid type (short-acting vs. long-acting) and dosing schedule

Risk Factors:

• Pre-Existing Diabetes or Prediabetes
• Family History of Diabetes
• Obesity, Metabolic Syndrome
• Higher Steroid Dose: Prednisone >7.5-10 mg/day
• Longer Duration of Steroids
• Older Age

Symptoms:

Often Asymptomatic (If Mild to Moderate Hyperglycemia)

If Significant Hyperglycemia:

• Increased thirst (polydipsia)
• Frequent urination (polyuria)
• Blurred vision
• Fatigue, weakness
• Increased hunger
• Slow wound healing
• Recurrent infections (yeast, UTIs)

Diagnosis:

Blood Glucose Monitoring:

• Before Starting Steroids: Baseline fasting glucose or HbA1c
• During Steroid Therapy:
  • Fasting Glucose: May be normal
  • Postprandial Glucose (2 hours after meals): Best reflects steroid effect—MOST IMPORTANT
  • Random Glucose: If symptoms present
• HbA1c: Less useful for short-term steroid use (reflects 2-3 month average); useful if long-term steroids

Diagnostic Criteria (Same as Diabetes):

• Fasting glucose ≥126 mg/dL (on 2 occasions)
• Random glucose ≥200 mg/dL with symptoms
• 2-hour postprandial glucose ≥200 mg/dL
• HbA1c ≥6.5% (if on long-term steroids)

Prevention:

• Use Lowest Effective Dose: For shortest duration
• Consider Steroid-Sparing Agents: If possible
• Alternate-Day Dosing: May reduce hyperglycemia (if clinically appropriate)
• Local/Inhaled Steroids: Instead of systemic (if possible)—lower risk
• Screen High-Risk Patients: Monitor glucose closely

Treatment:

Goals:

• Fasting glucose <130 mg/dL
• Postprandial glucose <180 mg/dL
• Avoid hypoglycemia

1. Lifestyle Modifications:

• Diet: Carbohydrate counting, portion control, low glycemic index foods
• Exercise: Improves insulin sensitivity (if patient able)
• Weight Management

2. Medications:

For Patients WITHOUT Pre-Existing Diabetes:

• Basal Insulin (NPH or Long-Acting): Most effective; targets afternoon/evening hyperglycemia
  • Start low (0.1-0.2 units/kg), titrate based on afternoon/evening glucose
  • NPH given in morning matches steroid peak better than long-acting
• Oral Agents (Less Effective but Easier):
  • Metformin: First-line oral; improves insulin sensitivity
  • Sulfonylureas (Glipizide, Glyburide): Stimulate insulin; risk of hypoglycemia
  • DPP-4 Inhibitors (Sitagliptin): Modest effect

For Patients WITH Pre-Existing Diabetes:

• Increase Existing Medications:
  • Increase basal insulin dose by 20-50% (or more)
  • May need to add or increase prandial (mealtime) insulin
  • Increase oral diabetes medications
• Close Monitoring: Frequent glucose checks, aggressive titration

3. Insulin Regimens (Most Effective for Moderate-Severe Hyperglycemia):

• Basal Insulin (NPH): Given in morning; covers afternoon/evening peak
• Basal-Bolus: Long-acting basal + rapid-acting at meals (if hyperglycemia all day)
• Premixed Insulin: NPH/Regular 70/30 in morning

Monitoring:

• Before Starting Steroids: Baseline glucose or HbA1c
• During Steroid Therapy:
  • Home glucose monitoring (fasting + 2 hours after meals, especially lunch/dinner)
  • Daily for high-risk patients or high-dose steroids
• Adjust Treatment: Based on glucose patterns
• After Stopping Steroids: Continue monitoring for 1-2 weeks; taper diabetes medications as glucose normalizes

What Happens After Stopping Steroids?

• Blood sugar usually normalizes within days to weeks after stopping steroids
• Taper Diabetes Medications: Especially insulin (to avoid hypoglycemia)
• Some Patients Develop Persistent Diabetes: Especially if pre-existing prediabetes or long-term steroid use
• Recheck HbA1c 2-3 months after stopping steroids

Long-Term Steroid Use:

• Risk of developing permanent diabetes increases
• Manage like type 2 diabetes (metformin, insulin, etc.)
• Screen for diabetes complications (retinopathy, nephropathy, neuropathy)