1/@kidney_boy asked a great question about when to split doses of NPH in patients requiring insulin for steroid-induced hyperglycemia. I thought Iβd post a 𧡠with some details β all from this really nice article by Aberer et al:
pubmed.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov
2/The hyperglycemic effect of the steroid will depend on whether it is short-acting (hydrocortisone), intermediate-acting (prednisone/prednisolone) or long-acting (dexamethasone). And β for short-acting and intermediate-acting steroids β how frequently they are dosed each day.
3/Short-acting steroid glycemic effects peak around 3 hours, and are gone by 6 hours. Rapid-acting insulins, or Regular insulin, are typically used to cover this effect Aberer et al. suggest a dose of 0.1 units of insulin per kg bodyweight β given with each dose of steroid.
4/Intermediate-acting steroid glycemic effects usually peak around 8 hours after a dose β and resolve by 12-16 hours. An insulin with an intermediate time of action should be used β this is where NPH (or detemir) comes in.
5/I tend to use NPH insulin β as the peak associated with NPH tracks with the peak in glycemic effect seen with the intermediate-acting steroids. Interestingly β there have been RCTs demonstrating non-inferiority of glargine compared with NPH.
pubmed-ncbi-nlm-nih-gov.evms.idm.oclc.org
pubmed-ncbi-nlm-nih-gov.evms.idm.oclc.org
6/Regarding dose β Aberer et al. recommend 0.2 u of NPH/kg if prednisone dose < 40 mg, or age > 70, or GFR < 30. OR β 0.3 u of NPH/kg if prednisone dose > 40 mg, or age < 70, or GFR > 30. Iβm going to start this in my practice.
7/If a second dose of prednisone is given in the evening, the patient may need a second dose of NPH. Iβd be cautious with evening insulin even in this setting due to risk for overnight hypoglycemia.
8/For those taking long-acting steroids like dex β NPH (or detemir) twice daily is reasonable β 0.3 units of NPH per kg per day total, split into 2/3 in am and 1/3 in evening. If someone is > 70 yo, or has a GFR < 30, can consider 0.15 u/kg.
9/Can also consider a longer-acting basal insulin like glargine or degludec β once per day β maybe 0.2 units per kg.
10/Long-acting steroid glycemic effects have a variable peak β and can last for up to 36 hours. This is important β as the day after a patient receives a high-dose of dexamethasone β they will likely still have some hyperglycemic effect.
11/Remember - insulin dosing when steroids are used can be difficult β and often an IV insulin drip is the way to go β at least initially. Especially if someone is on very high doses of steroids for short periods of time (acute organ rejection comes to mind).
12/And remember β patients with steroid-induced hyperglycemia (whether they have known diabetes or not) may have normal fasting glucose values β especially when a short- or intermediate- acting steroid is given once per day. So be cautious with evening insulin doses.
13/Aberer et al. also make recommendations re: insulin adjustment/intensification. I recommend checking out the article if you havenβt already. Required reading for anyone treating patients in the hospital (or out of the hospital really) with both steroids and insulin.
14/The article also discusses adjusting insulin therapy in people with type 1 diabetes on steroids β including those on insulin pumps. Everyone β I'm serious β itβs a REALLY good article
15/And that's all folks! For now π
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