Steroid Induced Hyperglycemia and Ketoacidosis

Introduction:

• Steroids increase insulin resistance, leading to hyperglycemia.
• Prior to starting therapy measure HbA1C- Levels >6.5% indicate pre-existing diabetes

Management:

• Patients who are on usual dose of Prednisolone (1mg/kg)- check 2hr post lunch and 2hr post dinner Blood Glucose (BG). If both values are <200mg/dl, then there is no need for further BG measurement and management of hyperglycemia.
• For patients exceeding this limit/ those on high dose steroids- NPH Insulin (Insugen N)- 0.1unit/kg for each 10mg Prednisolone/ 8mg Methyl prednisolone/ 1.5mg Dexamethasone to a maximum dose of 0.4units/kg. This should be given every morning along with dose of steroids
• For diabetic patients continue OHA as before. If they are on insulin continue that as well along with above dose of NPH insulin.
• Measure BG- 4times- Fasting, Pre-lunch, Pre-dinner and Post-dinner (2hrs)- This monitoring should be done for 2-3 days
• Target for Fasting, Pre-lunch, Pre-dinner is 110-150 mg/dL
• To achieve this Plain (Regular) insulin (Actrapid) is given subcutaneously as supplemental dose for these initial 2-3 days. For this sliding scale is followed: This should be given along with meals or up to 15min before.
  • 150-200 mg/dL- 4 Units
  • 201-250 mg/dL- 8 Units
  • 251-300 mg/dL- 12 Units
  • 301-350 mg/dL- 16 Units
  • >350 mg/dL- Evaluate for ketoacidosis and inform treating endocrinologist
• Assess BG values of 2 days, then fix the dose, based on these values.
  • If Post-dinner BG is high- increase pre-dinner dose
  • If pre-lunch BG is high- Increase Pre- breakfast dose
  • If pre-dinner BG is high- Increase pre-lunch dose
• Continue monitoring for next 2-3 days until target levels are achieved.
• Later monitor only fasting BG- If it is <150 mg/dL- No need to monitor whole day.
• Adjust the dose of insulin, when steroids are being tapered and stopped.
• Throughout the treatment patient should be on a consistent carbohydrate diet 

Diabetic Ketoacidosis

Precipitating factors:

• Inadequate insulin treatment
• Infections- Pneumonia, UTI etc
• Cardiovascular events
• Cerebrovascular accidents
• Pancreatitis
• Drugs
• Pregnancy

Pathogenesis:

Insulin deficiency

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Impaired glucose utilization by peripheral tissues

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Increased hepatic glycolysis and gluconeogenesis

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Hyperglycemia

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Increased cortisol and glucagon

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Inhanced lipolysis in adipose tissue

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Release of free fatty acids

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In liver free fatty acids are converted to keto acids

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1. Metabolic acidosis

2. Osmotic diuresis --> Hypokalemia and hyponatremia

Diagnosis:

• Blood Glucose (BG)- >250mg/dL
• Metabolic acidosis (Arterial pH- <7.3)
• Positive urine/plasma ketone bodies
• Serum bicarbonate <18mEq/L
• Dehydration
• Electrolyte abnormalities in varying degrees

Clinical Features:

• Vomiting/ Nausea
• Abdominal pain
• Laboured breathing (Kussmaul respiration)
• Polyurea

Treatment

• Correction of fluid deficit
  • 3 Lit NS (3 Lit 1/2 NS if Sodium is >145mEq/L)- At the rate of 1lit/hr
  • Start 5% dextrose when BG becomes <250mg/dL- At the rate of 100-200ml/hr
  • Continue fluids for 12 to 24 hrs
• Insulin (Plain/Regular only)
  • Start only if potassium level is >3.3mEq/L
  • Loading dose- 0.1 to 0.15 units/kg- IV bolus
  • Maintenance- 0.1unit/kg/hr as IV infusion
  • Monitor BG every hr and adjust dose of insulin accordingly
  • Goal is to decrease the BG 50-75mg/dL/hr
  • Change infusion rate by 50% if this goal is exceeded or not achieved
  • Target blood glucose is 150-200mg/dL
  • Once this is reached monitor BG once in 3 hrs
  • Once anion gap is closed, patient is able to eat and his mental status improves- change insulin from IV to Subcutaneous
• Potassium replacement
  • KCl - 20-60mEq in 500ml NS- over 6 hrs
• Acidosis correction
  • Correct acidosis only if HCO3 is <10mmol/L or pH is <7
  • Give 8.4% NaHCO3 as separate infusion- 100ml over 1-2hrs
• Look for signs of cerebral edema- Treat with mannitol, hypertonic saline, mechanical ventilation (Refer to intensivist)
• Treatment of underlying infections
  • Examine skin, feet etc
  • Chest X ray
  • Send urine and blood cultures
  • Start broad spectrum antibiotics emperically
• Monitor electrolytes- 4th hrly

Hypoglycemia

Blood glucose level-

• Men- <50mg/dL
• Women- <40mg/dL
• Infants- <30mg/dL

Management:

• Give glucose orally
• 50% dextrose- 50ml- IV Bolus, repeat if necessary. Add Inj. Thiamine- 100mg to drip
• 10% dextrose- Maintenance drip over next 24hrs
• Withhold insulin/OHA until blood glucose stabilizes
• Failure to recover may be due to cerebral edema- 
  • Give 20%-mannitol-  200ml stat
  • IV Dexamethasone 4mg- TDS
  • Glucagon-1mg- IM Stat, may be repeated after 10min