Steroid induced hyperglycaemia
DGRefHelp - NHS Dumfries & Galloway
Warning
Before starting steroids
- In people without known diabetes who are high risk, request HbA1c before or at point of starting starting steroids where practical to identify pre-existing undiagnosed diabetes.
- High-risk features include
- pre-diabetes
- previous steroid hyperglycaemia
- obesity
- previous gestational diabetes
- PCOS
- strong family history
- recurrent steroid courses
- Routine glucose monitoring is not required for every short rescue course of prednisolone in people without diabetes and without major risk factors.
- For low-risk patients on a short steroid course who are not monitoring, advise review if polyuria, polydipsia, weight loss, marked fatigue, infection, or clinical deterioration occurs.
Monitoring: patients without diabetes
If higher risk, symptomatic, clinically unwell, receiving repeated courses, or expected to continue systemic steroids beyond a short course:
- monitor capillary blood glucose once daily before / after lunch or evening meal. A fasting or morning reading can miss steroid hyperglycaemia.
Monitoring: pre-existing diabetes
- Use four-times-daily monitoring regardless of previous control.
- For high-dose steroids equivalent to >30 mg prednisolone daily, people with Type 1 Diabetes or insulin-treated Type 2 Diabetes may need insulin dose increases of around 40%.
- For basal-bolus insulin, increase both basal and quick-acting doses by around 40% from 12 hours after the first steroid dose, then adjust according to readings and duration of steroid treatment.
- If using sulphonylurea treatment, dose increases may be needed while monitoring for hypoglycaemia.
- Seek diabetes specialist advice for Type 1 Diabetes, insulin initiation, persistent hyperglycaemia, recurrent hypoglycaemia, frailty, pregnancy, palliative care, or complex steroid regimens.
Escalation thresholds
- If any blood glucose reading is >12 mmol/L, increase to four-times-daily testing.
- If blood glucose is >12 mmol/L on 2 occasions in 24 hours, consider treatment with a sulphonylurea or insulin depending on the clinical scenario.
Significantly unwell or BG >20 mmol/L
- If the patient is significantly unwell and blood glucose is >20 mmol/L, consider urgent medical assessment.
- A variable rate IV insulin infusion (VRII / VRIII) may be needed as a temporary measure in hospital.
- For Type 1 Diabetes or ketosis symptoms, check ketones and manage as possible DKA if indicated.
When steroids reduce or stop
- Reduce sulphonylurea and/or insulin doses in tandem with steroid dose reductions to avoid hypoglycaemia.
- JBDS notes that a weekly 5 mg reduction of prednisolone from 20 mg may require a 20-25% insulin dose reduction or a 40 mg gliclazide reduction; individualise to glucose readings and clinical context.
- Continue monitoring until normoglycaemia returns or diabetes is confirmed / excluded.
- If steroid-induced hyperglycaemia occurred, screen for persistent diabetes after steroid cessation. If using HbA1c, delay until around 3 months after steroids stop; consider fasting glucose earlier if diabetes is clinically suspected.
Referral / advice
- Use SCI Gateway for diabetes advice or referral where management is suboptimal on maximum tolerated oral agents or insulin adjustment is needed.
- Include steroid name, dose, timing, expected duration and taper plan; current diabetes treatment; glucose readings with timing; HbA1c; renal function; ketone results if relevant; and symptoms / acute illness status.
Sources: NHS D&G Clinical Handbook article 'Hyperglycaemia & Steroids' (last updated 5 October 2020), JBDS 08 Management of Hyperglycaemia and Steroid Therapy, January 2023, and primary-care literature on steroid-induced hyperglycaemia. JBDS is primarily an inpatient guideline; this section adapts relevant outpatient and community monitoring principles.