What is Steroid-induced Diabetes and How is It Treated?

Short-term cortisone therapy is used in various fields:

• It is a valuable aid in resolving acute issues, especially allergic and anaphylactic reactions;
• It is indicated in pulmonology for managing asthma, allergies, and exacerbations of chronic bronchitis;
• In oncology, it is part of various chemotherapy protocols;
• In gynecology, it is used for fetal lung maturation in cases of preterm delivery;
• In neurology, it helps resolve cerebral edema or treat meningitis;
• In endocrinology, it is used to treat subacute thyroiditis.

Long-term cortisone use, sometimes over several years, is prescribed for:

• Rheumatologic conditions (rheumatoid arthritis, lupus, polymyalgia rheumatica);
• Hematologic conditions (lymphomas, multiple myeloma);
• Pulmonology (idiopathic interstitial pneumonia, hypersensitivity pneumonia, sarcoidosis);
• Chronic autoimmune and inflammatory diseases (arteritis, glomerulonephritis, autoimmune hepatitis, chronic inflammatory bowel diseases);
• Neurological conditions (multiple sclerosis, myasthenia gravis).

Additionally, it is also used in anti-rejection therapy following organ transplantation.

Steroid-induced diabetes, also called metasteroid diabetes, refers to elevated blood sugar levels observed during corticosteroid therapy in patients with or without a previous history of diabetes.

“This does not mean that all patients taking steroids are destined to become diabetic,” explains Dr. Savulescu. “However, it is a common condition that occurs on average in 20% (range 10-60%) of people treated with steroid therapy for prolonged periods.”

The onset of hyperglycemia is related to individual patient factors, the condition being treated with steroids, and the type of steroid therapy.

Patient-Related Risk Factors

Patient-related risk factors include:

• age, genetic predisposition to diabetes/family history, previous prediabetic condition;
• fasting hyperglycemia, impaired carbohydrate tolerance;
• obesity or metabolic syndrome (high blood pressure/dyslipidemia);
• previous gestational diabetes or steroid-induced diabetes;
• comorbidities.

Therapy-Related Risk Factors

Therapy-related risk factors include:

• type of condition being treated with steroids;
• type of molecule (short- or long-acting);
• dose (high or low doses) and dosage (once or twice a day) of the drug;
• duration of therapy: short-, medium-term (6 months), or long-term (over 5 years);
• continuous treatment rather than bolus cortisone therapy;
• type of administration: oral, injectable, inhaled, topical, or ocular.

“The diagnosis of steroid-induced diabetes,” explains Dr. Savulescu, “is based on checking blood sugar levels 2 hours after lunch, rather than fasting blood sugar, which often appears normal. This is the main reason why metasteroid diabetes is often diagnosed with a delay. However, the diagnosis is made earlier if risk factors for diabetes are considered and if the patient is hospitalized.”

The HbA1c glycosylated hemoglobin test is less reliable due to possible interference from other concomitant conditions (e.g., hematologic, hepatic, or renal diseases).

“Those suffering from this condition,” emphasizes Dr. Savulescu, “should be educated to follow a different method of blood glucose monitoring, with measurements of capillary blood glucose 2 hours after lunch, and before and after dinner.”

In managing diabetic patients undergoing steroid therapy for another condition, it is essential to consider:

• aspects related to diabetes (good glycemic control with personalized targets based on the patient’s characteristics, specific contraindications like organ failure, or possible side effects of hypoglycemic drugs that impact therapy);
• the condition requiring steroid treatment.

“Insulin therapy,” explains the specialist, “is the safest and most effective option for treating steroid-induced diabetes due to its flexibility and ease of management.”

Currently, the use of incretin-based medications offers a valid alternative to insulin therapy. Acting on some of the main causes of steroid-induced hyperglycemia (increased insulin secretion and reduced glucagon secretion after meals), these drugs provide targeted control of postprandial blood glucose, with the added benefit of a lower risk of hypoglycemia.

Another advantage is that they can be used in patients with kidney issues and also have beneficial effects on body weight (GLP-1). Combining this therapy with insulin may also be beneficial, as it can reduce the number of injections needed.

"An important point to keep in mind," emphasizes the diabetologist, "is adjusting and modifying hypoglycemic therapy if the steroid treatment is gradually reduced or discontinued. Discontinuation does not always result in the disappearance of diabetes, which may require chronic management!"