The high incidence of steroid-induced hyperglycaemia in hospital

Abstract

Aim

The objective of this study was to systematically evaluate the incidence of steroid-induced hyperglycaemia in a tertiary referral hospital. We conducted a glucometric audit of a prospective protocol where glucose monitoring was routinely performed on patients treated with high-dose steroids.

Methods

The protocol specified routine fingerprick glucose monitoring for patients commencing high-dose steroid therapy (prednisone 25 mg/day, dexamethasone 4 mg/day, hydrocortisone 100 mg/day, or more) for a minimum of 48 h. The medical records and charts of these patients were audited after a 6 month period.

Results

There were 80 non-diabetic patients treated with high-dose steroids and 862 blood glucose (BG) readings were recorded. The mean BG was ≥8 mmol/L in 38 (48%) patients and ≥10 mmol/L in 11 (14%) subjects. Sixty-nine (86%) subjects had at least one BG ≥8 mmol/L, and 56 (70%) subjects had at least one BG ≥10 mmol/L. Among those with hyperglycaemia, it had developed within 48 h in 94% of subjects. When prednisone was administered as a once daily morning dose, glucose levels peaked in the afternoon, and would return to baseline by the next morning.

Conclusions

We conclude that steroid-induced hyperglycaemia is common in hospital. Patients should be monitored for hyperglycaemia upon commencement of high-dose steroid therapy and treatment commenced as indicated.

Introduction

Hyperglycaemia, even in patients who are not known to have diabetes, is common in hospital. It has been associated with increased mortality in critically ill patients [1], [2], [3], as well as in the general hospital population [4], [5]. There is evidence for increased infection rates [6], [7], [8] and a recent meta-analysis has confirmed that tight glucose control reduces the risk of infection [9].

High dose steroid therapy is a recognised precipitant of hyperglycaemia both in people with diagnosed diabetes, and in those who do not have known diabetes. Steroid therapy itself predisposes to infection and poor wound healing. As the addition of hyperglycaemia could potentially exacerbate these complications, hyperglycaemia amongst steroid treated patients is not a trivial matter.

Given the frequency of steroid use in hospital, it is surprising that there is a paucity of literature regarding the incidence of steroid-induced hyperglycaemia. One 2009 review found only 4 publications, none of which were in the hospital setting [10]. A retrospective hospital audit found that of 34 non-diabetic patients who had glucose measurements during high dose steroid therapy, 56% had at least one episode of hyperglycaemia defined as a glucose level ≥11.1 mmol/L [11]. A recent study using continuous glucose monitoring found that 53% of patients receiving prednisone for chronic obstructive pulmonary disease had at least one episode of hyperglycaemia, defined as a glucose level ≥10 mmol/L [12].

As we also have the experience that hyperglycaemia is common amongst patients receiving high dose steroid therapy, we undertook a glucometric study with a prospective protocol to systematically assess the effect of steroid therapy on glucose levels. The main aim of the study was to determine the incidence of steroid-induced hyperglycaemia in a tertiary hospital setting. A secondary objective was to examine the glucose profile of patients receiving once daily steroid therapy, as there has been debate about the most appropriate insulin to administer in this situation.