MANAGEMENT OF ADULTS WHO ARE
HYPERGLYCAEMIC DURING
THE USE OF STEROID THERAPY
Reference Number
N/A
Version
1
Name of responsible (ratifying) committee
Formulary and Medicines Committee
Date ratified
17.09.2010
Document Manager
Diabetes Specialist Nursing team
Diabetes/Endocrinology Consultant team
Date issued
04.10.2010
Review date
September 2012
Electronic location
Corporate Clinical Guidelines
Related Procedural Documents
See section 8 References and Associated
Documentation
Key Words (to aid with searching)
Diabetes; Hyperglycaemia; Steroids
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CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 4
DEFINITIONS .............................................................................................................................. 4
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
PROCESS ................................................................................................................................... 6
TRAINING REQUIREMENTS ...................................................................................................... 7
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 7
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS .............................................................................................................................. 7
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QUICK REFERENCE GUIDE
This guideline must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. Recognition that high dose steroids can result in hyperglycaemia in both patients who have
pre existing diabetes and those who have not been diagnosed with diabetes are most likely
fall into a high risk group.
2. Be aware that hyperglycaemia secondary to steroid administration may result in the need to
increase existing insulin doses or lead to the introduction of subcutaneous insulin.
3. Acknowledgement of which patients may be more likely to require introduction of insulin
therapy and therefore require close monitoring
4. To be familiar with the treatment algorithm for: Glucocorticoid Induced Hyperglycaemia
5. Identify and organise appropriate follow up
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1. INTRODUCTION
The use of steroid therapy in people who have diabetes mellitus (diabetes) will undoubtedly
raise their blood glucose levels and precipitate the need for temporary additional treatment.
This is known as steroid induced hyperglycaemia. However, this rise in glucose can also occur
in a person who ordinarily does not have diabetes. This is referred to as steroid induced
diabetes and may or may not disappear once the steroids have been discontinued. Steroid
induced diabetes most likely precipitates diabetes in predisposed (high risk) individuals1.
This guideline is designed to assist medical and nursing staff to manage a person who has
diabetes and whose glucose levels are found to be elevated secondary to the use of steroids,
or patients who have not previously been diagnosed with diabetes but are hyperglycaemic.
Early recognition and treatment is essential as major metabolic decompensation and coma can
ensue1. This document will guide you to appropriate glucose monitoring and subsequent
decisions regarding the need for additional or introductory treatment and follow up.
2. PURPOSE
The purpose of this guideline is to:
 Promote awareness of how steroids affect glycaemic control
 Create an understanding of suitable treatment options
 Ensure implementation of treatment is timely
 Promote awareness of appropriate glucose testing
 Ensure appropriate follow up for patients who have required additional or introductory
treatment
3. SCOPE
This guideline applies to all registered nursing staff and clinicians working within PHT involved
in prescribing the steroids and day to day care of adult patients.
This guideline should be used in conjunction with:
 Insulin therapy administration and management guideline
 Blood Glucose Monitoring For Inpatients
This guideline excludes outpatient clinic settings, community based patients and pregnant
ladies
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be
possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their
manager and all possible action must be taken to maintain ongoing patient and staff safety’
4. DEFINITIONS
Diabetes:
Type 1 diabetes is an autoimmune disease characterised by hyperglycaemia resulting from
absolute deficiency of insulin affecting a heterogeneous group of people
Type 2 diabetes is a metabolic disease characterised by hyperglycaemia resulting from relative
insulin deficiency and insulin resistance affecting a heterogeneous group of people
Steroids:
Steroids are a group of medicines that can be used for their anti-inflammatory properties or as
replacement therapy in various endocrine disorders. This includes corticosteroids, most
commonly Prednisolone and Dexamethasone.
Blood glucose levels in people who have endocrine disorders such as Addisons disease and
pituitary disease on replacement steroids are unlikely to be affected.
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Common clinical areas prescribing high dose steroids are: haematology, respiratory, oncology,
rheumatology and general medicine.
Steroid induced Hyperglycaemia:
Corticosteroids have an especially potent diabetogenic effect and act by inducing insulin
resistance2.
Steroid induced diabetes:
Dosages equivalent to ≥30 mg/day of prednisolone are especially likely to raise blood glucose
in people who have diabetes but may cause glucose intolerance or overt diabetes in previously
normoglycaemic individuals2.
Optimal blood glucose levels for people who have diabetes3:
 Pre prandial (before a meal)
5 – 7 mmols/l
 Post prandial (2 hours after a meal) 7 – 9 mmols/l
 Before bed
9 mmols/l
 It may be appropriate for certain groups of patients to aim for higher glucose levels than
those stated above to minimise the risk of hypoglycaemia, for example 8 – 12 mmols/l.
These groups may include those at risk of falling, have a low / variable appetite,
confusion or memory problems. A glucose target should be set for each individual
patient, i.e. Mrs A should aim for glucose levels of <8mmols/l but Mr B should aim for
glucose levels <12 mmols/l
Typical blood glucose patterns when steroids are introduced4:
Typically a person who administers steroids in the morning will display glucose levels which
start to rise mid morning and continue through to bed time. Blood glucose levels may be over
20mmols/l at this time. Overnight the glucose levels often drop to single figures. Multiple
doses of steroids may cause a hyperglycaemic effect across the whole day.

You may expect glucose levels to rise approximately:
o 14 - 18hours after administration of oral steroids
o 5 hours after administration of intravenous steroids

You may see glucose levels improving to pre steroid levels approximately:
o 24hours after intravenous steroids are discontinued
o as oral steroids are weaned down over several weeks the glucose levels will
decline gradually
High Risk Groups more likely to develop hyperglycaemia if not already known to have diabetes3
 Obese – especially truncal obesity
 Family history of diabetes
 Previous gestational diabetes or birth of a large baby for dates
 Ethnic minorities
 Those with existing coronary heart, cerebrovascular disease, peripheral vascular
disease or hypertension
 Obese ladies who have polycystic ovary disease (PCOS)
 Those known to have Impaired fasting glucose or impaired glucose tolerance
Additional treatment4:
(a) Insulin therapy may be required in individuals who have Type 2 diabetes and are either
dietary managed or already on oral anti-diabetic agents, and those with hyperglycaemia who
have not previously been diagnosed with diabetes. Initially, it would be appropriate to prescribe
an Isophane basal insulin (e.g. Humulin I or Insulatard). A total daily dose of 0.5 units / kg body
weight may be required but a safe starting dose would be administered initially (see Process
algorithm)
(b) Insulin doses for those individuals already on insulin (for both Type 1 and 2 diabetes) may
need increasing by up to 50% and adjusted according to response.
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5. DUTIES AND RESPONSIBILITIES
Prescriber:
 The prescriber of the steroid should identify whether the patient has pre-existing
diabetes. If so, the nursing staff should be made aware of the likely risk to glycaemic
control
 Increase the patients usual insulin doses or prescribe insulin therapy as required (see
Process algorithm) once capillary glucose levels have been reviewed. Adjust dose
according to response
 If a patient without pre-existing diabetes is commenced on high dose steroids,
especially if they fall within a high risk category, doctors should inform nursing staff so
they can initiate blood glucose monitoring. If glucose levels are greater than 8 –12
mmols/l the treatment algorithm for Glucocorticoid Induced Hyperglycaemia should be
followed (see Process)
Nursing staff:
 To ensure capillary blood glucose is monitored QDS. If glucose levels exceed 8 – 12
mmols a clinician and specialist diabetes team should be informed
 Administer increased insulin dose or introduce insulin at the earliest opportunity once it
has been prescribed. Continue to monitor capillary blood glucose levels QDS and
inform clinicians of effect
6. PROCESS
1) Treatment algorithm for: Glucocorticoid Induced Hyperglycaemia:
Glucocorticoid Induced Hyperglycaemia
Random blood glucose >8 - 12mmol/l and steroids administered at:
Breakfast time
only
More than once
daily
Already
administering
insulin
Not on insulin
therapy
Already
administering
insulin
Not on insulin
therapy
Increase normal
insulin by 4units
Introduce Humulin
I or Insulatard
insulin at 12 units
early morning
Increase normal
insulin by 4units
Introduce Humulin
I or Insulatard
insulin at 8 units
morning and
evening
Monitor glucose levels 6
hourly. If over half glucose
levels remain >target, and
no value <6mmols/l,
increase insulin each day
by 4units
Monitor glucose levels 6
hourly. If over half glucose
levels remain >target, and
no value <6mmols/l,
increase insulin each day
by 4units
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2) Returning to usual insulin doses or stopping4:
a. Patients who were administering insulin prior to steroid therapy: advise patient
that insulin will most likely need to be weaned down to the original doses 24hrs
after steroids have been discontinued. Patient may wish to have follow-up with
their GP or diabetes centre. Please refer on OCM if diabetes centre follow up
required
b. Patients who were not administering insulin prior to steroid therapy: as steroids
are reduced, wean down insulin according to glucose levels and withdraw 24hrs
after steroids have been discontinued. Follow up with GP.
3) Discharge:
a. If patient is to be discharged on high dose steroids please refer to specialist
diabetes team via OCM referral system at the earliest opportunity.
7. TRAINING REQUIREMENTS
All staff involved in the prescribing and administration of steroids should have read this
guideline
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Krentz A and Bailey C (2001). Type 2 Diabetes – in Practice. Royal Society of Medicine
Press Ltd, London
2. Williams G and Pickup J (2004) Handbook of Diabetes 3rd Ed. Blackwell Publishing Ltd,
Oxford
3. www.diabetes.org.uk
4. There is little research surrounding the use of steroids and diabetes mellitus. Therefore some
of the information given in this guideline is of expert opinion.
9. MONITORING COMPLIANCE
PROCEDURAL DOCUMENTS
WITH,
AND
THE
EFFECTIVENESS
OF,
The effectiveness in practice of all procedural documents should be routinely monitored
(audited) to ensure the document objectives are being achieved. The process for how the
monitoring will be performed should be included in the procedural document.
The details of the monitoring are:

Management of patients with diabetes who are prescribed steroid therapy will be
monitored during daily diabetes ward rounds.

Specialist diabetes team will discuss unfavorable steroid management issues with staff
during ward rounds or via adverse incident reporting

Annual diabetes audits will capture glucose/steroid management. Results of the audit
will be considered by the specialist diabetes team and any educational needs will be
identified.
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