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Corticosteroids and Insulin Dose Adjustment

Why Corticosteroids Raise Blood Glucose

• Increased insulin resistance (peripheral glucose utilization falls)
• Increased hepatic glucose production (gluconeogenesis)
• Impaired insulin secretion (beta-cell dysfunction)
• Lipolysis and proteolysis providing gluconeogenic substrate

• Dose-dependent - more steroid = more hyperglycemia
• Postprandial-predominant with intermediate-acting steroids (e.g., prednisone)
• Around-the-clock with long-acting steroids (e.g., dexamethasone)
• Usually reversible when steroids are tapered/stopped

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Step 1 - Assess Baseline Status

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Step 2 - Match Insulin Strategy to Steroid Type

Once-daily morning prednisone / prednisolone (intermediate-acting)

• Add NPH in the morning with (or just after) the steroid dose
• NPH's peak action at 4-8 hours matches the steroid-induced glucose peak
• Initial dose based on prednisone dose:

• Alternatively: start NPH at 10 units in the morning; up-titrate by 10-20% daily based on morning glucose
• If patient is already on basal-bolus insulin: increase the AM basal or premixed insulin dose by 20%, then titrate by 10% increments

• Give extra rapid-acting insulin with breakfast/lunch to blunt the post-steroid spike
• This shifts the rapid:basal ratio above the usual 50:50

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Long-acting steroids (dexamethasone, methylprednisolone)

• Use twice-daily NPH (initial dose: 0.3 IU/kg BW/day divided) or
• Use long/ultra-long-acting basal analog (glargine U100/U300 or degludec), initial dose 0.2 IU/kg/day
• Reassess glucose 24 hours after steroid intake; up-titrate by 20% if BG >18 mmol/L (>320 mg/dL), or 10% if BG 12.1-18 mmol/L (220-320 mg/dL)

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Short-acting steroids (hydrocortisone)

• A rapid-acting insulin bolus at the time of hydrocortisone administration is often sufficient
• Add a corrective rapid-acting dose 3-4 hours later if glucose remains elevated
• The rapid:basal insulin ratio will exceed 50:50 temporarily

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Step 3 - Insulin Titration Rule of Thumb

Adjust insulin by half the percentage of the GC dose change.

Example: GC increased 50% → increase insulin dose by ~25% Example: GC tapered 40% → reduce insulin dose by ~20%

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Step 4 - Stopping Steroids (Taper/Discontinuation)

• Once steroids are stopped, reduce insulin by 50% immediately, then down-titrate further per glucose levels (hyperglycemia may take a few days to fully resolve)
• Patients established on insulin before steroids were started: return to pre-steroid doses (or reduce by 50% if pre-admission dose not known)
• Patients on oral agents before (who needed insulin for steroids): stop the insulin and resume oral therapy

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Special Notes

• Type 1 diabetes: More prone to hypoglycemia when doses are increased. Adjust more cautiously; consider endocrinology input.
• In-hospital targets: Glucose 6-10 mmol/L (108-180 mg/dL), accepting 4-12 mmol/L (72-216 mg/dL) for most patients. Avoid tight control in the frail elderly, confused patients, or those with dementia.
• Monitoring: Check blood glucose before meals and at bedtime. More frequent monitoring during steroid initiation, dose changes, or tapering.
• Outpatient setting: If FPG is near normal, a sulfonylurea (e.g., glipizide) taken with breakfast may be adequate for once-daily morning prednisolone. Insulin is still preferred when FPG >200 mg/dL.

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Quick Reference Summary

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IV Insulin Infusion Protocol (Continuous Insulin Infusion - CII)

Indications

• Critical illness hyperglycemia (BG persistently ≥180 mg/dL in the ICU)
• Diabetic ketoacidosis (DKA) and Hyperglycemic Hyperosmolar State (HHS)
• Perioperative glucose management (cardiac surgery, major surgery, transplant)
• TPN/TEN with unstable glucose requirements
• NPO patients with rapidly changing insulin needs
• Situations requiring precise, rapid titration

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Glucose Targets by Society Guideline

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Preparation

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Step 1 - Initiating the Infusion

• Two consecutive BG ≥150 mg/dL, or
• Single BG ≥200 mg/dL

Initial Bolus (optional, situational)

Bolus dose = BG (mg/dL) ÷ 100 (round to nearest unit) Example: BG = 280 → give 2-3 units IV bolus, then start infusion

Starting Infusion Rate

Initial rate (units/hr) = BG (mg/dL) ÷ 100 Example: BG = 240 mg/dL → start at 2.4 units/hr

• Insulin-sensitive: 0.02-0.05 units/kg/hr
• Usual ICU patient: 0.05-0.1 units/kg/hr
• Insulin-resistant: 0.1-0.2 units/kg/hr

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Step 2 - Titration Algorithm (Nurse-Driven, Hourly)

Standard Algorithm Table (Nurse-Led ICU Protocol)

Algorithm Movement Rules

Titration Rule of Thumb (Simpler Approach - Portland Protocol style)

Rate (units/hr) = [BG - 60] × multiplier

• Start with multiplier = 0.02
• After two successive BG >130: increase multiplier
• If BG <100: decrease multiplier
• If BG <60: set multiplier to zero

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Step 3 - Monitoring Frequency

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Step 4 - Hypoglycemia Management

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Step 5 - Special Situations

DKA Protocol (differs from general CII)

• Bolus: 0.1 units/kg IV before starting infusion
• Infusion: 0.1 units/kg/hr
• When BG reaches 250 mg/dL: reduce to 0.05 units/kg/hr and add dextrose to IV fluids (D5 or D10 in 0.45% NaCl) to maintain BG 150-200 mg/dL until anion gap closes and patient can eat
• Do not stop insulin prematurely - continue until ketosis resolves

Perioperative (cardiac/major surgery)

• Target: <180 mg/dL intraoperatively
• Preferred over SC insulin for all major procedures
• Society of Thoracic Surgeons recommends CII as preferred method in cardiac surgery

TPN patients

• After determining total daily insulin requirement via separate insulin infusion, a portion may be added directly to the TPN bag for nutritional coverage
• Continue a separate infusion for fine-tuning and correction

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Step 6 - Transitioning Off IV Insulin to Subcutaneous

1. Calculate the total insulin used in the last 6-8 hours × 4 (or last 24-hour IV insulin total)
2. Give 80% of total daily requirement as SC insulin:
   • 50% as basal (glargine or detemir once or twice daily)
   • 50% as prandial (rapid-acting with each meal, split equally)
3. Administer the first SC dose 1-2 hours before stopping the infusion (to allow SC depot to build)
4. Continue BG monitoring every 1-2 hours for the first 4-6 hours after transition

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Notify the Physician When:

• BG change >100 mg/dL between two consecutive readings
• BG ≥300 mg/dL
• Hypoglycemia not responding to dextrose within 20 minutes
• Algorithm 4 is insufficient (consult endocrinology)
• Patient develops clinical signs of hypoglycemia at any BG level

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Quick Reference Card