Interactive diabetes case 9: Management of type 1 diabetes in a patient on glucocorticoid therapy – A2

ANSWER — Correct.

The patient and allergist report that the patient requires systemic steroids for several months each year during the allergy season and will be on prednisone for the next three to four months, probably at a dose of 20 to 30 mg a day in the morning.

The management of glucocorticoid-induced hyperglycemia depends, in part, on the anticipated duration of glucocorticoid therapy. If the anticipated course is brief (as an example, one to two weeks), it may be sufficient to increase the doses of short-acting or very short-acting insulin and to avoid a change in the dose of the basal (intermediate or long-acting) insulin, the effect of which will be difficult or impossible to assess when the insulin requirement is falling as the steroid is tapered. If the anticipated dose is longer, it is helpful to increase the basal insulin dose as well.

What is your plan now?

●You increase the dose of NPH insulin to 20 units before breakfast and 10 units at bedtime. You add to the current doses of regular insulin before breakfast and supper an insulin correction factor before meals and at bedtime using a generous correction factor of 20, ie, 1 unit of short-acting (regular) insulin for every 20 mg/dL (1.1 mmol/L) elevation of the blood glucose level above a reference point of 120 mg/dL (6.7 mmol/L), approximately twice the correction factor one might otherwise use. (Based on the patient's insulin doses before the start of prednisone and using the rule of 1500, the correction factor would otherwise be 39.5.) An approach to estimating the dose of short- and very short-acting insulins is discussed separately (see "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B2"). You anticipate further adjustment of the new insulin regimen as the patient monitors the blood glucose values on it and as the dose of prednisone is tapered. (See "Interactive diabetes case 9: Management of type 1 diabetes in a patient on glucocorticoid therapy – B1".)

●You increase the dose of NPH insulin to 20 units before breakfast and do not change the dose of NPH at bedtime. You add to the current doses of regular insulin before breakfast and supper an insulin correction factor before breakfast and lunch using a generous correction factor of 20, ie, 1 unit of short-acting insulin (regular in this case) for every 20 mg/dL (1.1 mmol/L) elevation of the blood glucose level above a reference point of 120 mg/dL (6.7 mmol/L), approximately twice the correction factor one might otherwise use. (Based on the patient's insulin doses before the start of prednisone and using the rule of 1500, the correction factor would otherwise be 39.5.) An approach to estimating the dose of short- and very short-acting insulins is discussed separately (see "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B2"). You anticipate further adjustment of the new insulin regimen as the patient monitors the blood glucose values on it and as the dose of prednisone is tapered. (See "Interactive diabetes case 9: Management of type 1 diabetes in a patient on glucocorticoid therapy – B2".)

●You change the insulin regimen to glargine insulin 20 units at bedtime and lispro insulin. You substitute lispro insulin for regular insulin before meals. You add to these doses of very short-acting insulin an insulin correction factor before meals and at bedtime using a generous correction factor of 20, ie, 1 unit of very short-acting insulin (lispro in this case) for every 20 mg/dL (1.1 mmol/L) elevation of the blood glucose level above a reference point of 120 mg/dL (6.7 mmol/L), approximately twice the correction factor one might otherwise use. (Based on the patient's insulin doses before the start of prednisone, and using the rule of 1500, the correction factor would otherwise be 39.5.) An approach to estimating the dose of short- and very short-acting insulins is discussed separately (see "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B2"). You anticipate further adjustment of the new insulin regimen as the patient monitors the blood glucose values on it and as the dose of prednisone is tapered. (See "Interactive diabetes case 9: Management of type 1 diabetes in a patient on glucocorticoid therapy – B3".)