The high incidence of steroid-induced hyperglycaemia in hospital
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.
Section snippets
Materials and methods
A protocol for routine testing of fingerprick blood glucose (BG) amongst patients commenced on high dose steroid therapy was established in Westmead Hospital, a tertiary referral hospital. The protocol focused on units where steroid therapy is commonplace: the respiratory, immunology, rheumatology and oncology units were targeted. High dose steroid therapy was defined as prednisone 25 mg/day or more, dexamethasone 4 mg/day or more, hydrocortisone 100 mg/day or more, where it was likely to be
Results
Blood glucose monitoring results were available on 80 non-diabetic hospital patients treated with high dose steroids. Their mean age was 62 ± 18 years. There were 39 men and 41 women. There were 49 subjects treated with prednisone only, 18 with dexamethasone only, 4 with hydrocortisone only and 9 with a combination. Steroid therapy was commenced in 55 subjects for respiratory disease, 5 for rheumatological conditions, 20 as part of treatment of malignant disease, and 2 for gastroenterological
Discussion
We have confirmed that hyperglycaemia is common amongst non-diabetic patients treated with high-dose steroid therapy in hospital. A recent guideline from the Endocrine Society (USA) suggested a threshold of 7.8 mmol/L (140 mg/dL) for the definition of inpatient hyperglycaemia [14]. Using our similar pre-defined cut-off of 8 mmol/L (144 mg/dL), we found that the vast majority, 86% of patients on high dose steroids, had at least one episode of hyperglycaemia, and the mean BG was above this level for
Previous presentation
This data has previously been presented at the Australian Diabetes Society Annual Scientific Meeting, September 2012, Perth, Australia.
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgement
This research was supported by a peer reviewed Australian Diabetes Society – Servier National Action Plan Research Grant.
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