Interactive diabetes case 9: Management of type 1 diabetes in a patient on glucocorticoid therapy – A3

ANSWER — Incorrect.

Although the blood glucose values improve before lunch and supper, the patient develops recurrent hypoglycemia between 3:00 and 4:00 AM.

When a short-acting glucocorticoid such as prednisone is given once a day in the morning to a patient with diabetes, the hyperglycemic effect is most pronounced during the first 8 to 12 hours after the dose, especially after meals. Typically the effect is minimal or absent the following morning. The time course of the hyperglycemic effect of prednisone in this case is evident before the patient comes to see you, with the highest blood glucose values before lunch and before supper, less elevated values at bedtime, and values that are minimally above baseline before breakfast.

At the start of once-a-day prednisone therapy, it is usually appropriate to increase the doses of insulin before breakfast and before lunch. This may be a sufficient response to the addition of a morning dose of prednisone and, by preventing the acute rise of the blood glucose level after breakfast and before and after lunch, may improve the glucose values at bedtime and the following morning. By increasing the insulin doses not only before breakfast and lunch, but also before supper and at bedtime, the patient is placed at increased risk of hypoglycemia at night or in the early morning.

In a patient on prednisone in the morning, it is usually appropriate to increase the insulin doses before breakfast and lunch at the start, to assess the response to the intervention every one to two days, and to make further adjustments in insulin doses in an iterative manner.

Return to the beginning to try again. (See "Interactive diabetes case 9: Management of type 1 diabetes in a patient on glucocorticoid therapy".)