Glycemic management on systemic glucocorticoid therapy: more data needed

  • Tatalovic M & al.
  • BMJ Open
  • 01/06/2019

  • Miriam Tucker
  • Clinical Essentials
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Takeaway

  • Achieving effective glycemic control in patients with type 2 diabetes (T2D) initiating systemic glucocorticoid therapy is difficult.
  • Obstacles include heterogeneity of populations, interventions, target glucose levels, and glucose monitoring in available studies, and low-moderate quality of evidence.
  • Even for the widely recommended basal-bolus insulin (BBI) regimens, data are inconclusive.

Why this matters

  • Steroid treatment in patients with diabetes is common, but often leads to or exacerbates hyperglycemia.

Study design

  • Systematic literature review yielded 8 articles reporting studies including 481 individuals (343 with diabetes, 138 with glucocorticoid-induced hyperglycemia).
  • Funding: None.

Key results

  • In 6 studies of BBI regimens, divergence in designs (i.e., in use of sliding-scale insulin [SSI] regimens, intermediate- vs long-acting insulin, and dosing) “precluded a clean and coherent quantitative meta-analysis.”  
  • In 3 trials comparing NPH with glargine in BBI regimens, overall glycemic control did not differ significantly between them.   
  • In 1 study comparing addition of SSI or intermediate-acting insulin (IMI) to established diabetes medication, IMI produced greater time in target glucose range (P<.001 and lower mean daily glucose>
  • No studies compared anticipatory vs compensatory adjustments.

Limitations

  • Low-moderate evidence quality.
  • Lack of comparability.
  • Inclusion of populations with type 1 diabetes, and T2D with and without baseline insulin treatment.