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Mixing Glucocorticoids WITH DIABETES

By: Tamara R Meier, MS, APRN, CCNS. Mixing Glucocorticoids WITH DIABETES. OBJECTIVES. Analyze medications used to treat diabetes mellitus Determine therapy for treatment of glucocorticoid induced hyperglycemia Develop treatment plan for diabetics requiring glucocorticoid therapy.

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Mixing Glucocorticoids WITH DIABETES

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  1. By: Tamara R Meier, MS, APRN, CCNS Mixing Glucocorticoids WITH DIABETES

  2. OBJECTIVES • Analyze medications used to treat diabetes mellitus • Determine therapy for treatment of glucocorticoid induced hyperglycemia • Develop treatment plan for diabetics requiring glucocorticoid therapy

  3. DIABETES • TYPE 1 • TYPE 2 • INSULIN RESISTANCE • PREDIABETES • GLUCOCORTICOID INDUCED DIABETES

  4. RANGES • HGA1C • Prediabetes= 5.5-6.4% • DM= >6.5% • FASTING • <100 mg/dl • BEFORE MEALS • <100 mg/dl • 2 HR AFTER MEALS • <140 mg/dl

  5. GLUCOCORTICOIDS • HYDROCORTISONE • SOLU-MEDROL • SOLU-CORTEF • PREDNISONE • MEDROL DOSE PACK • PREDNISOLONE

  6. DISEASES TREATED WITH GLUCOCORTICOIDS • COPD • BRONCHITIS • TRANSPLANT • CANCER • CYSTIC FIBROSIS • GOUT • PAIN

  7. MEDICATIONS FOR DIABETES • ORAL AGENTS • INSULIN SENSITIZERS • SULFONUREAS • INJECTIONS • INSULINS • BASAL • BOLUS • INCRETIN MIMETICS • BYETTA • VICTOZA

  8. GLUCOCORTICOID INDUCED DIABETES • NO PRIOR HISTORY OF DIABETES • PATIENT IS STRESSED • SURGERY • TRAUMA • ILLNESS • HYPERGLYCEMIA • PRE-MEAL • POST MEAL

  9. GLUCOCORTICOID INDUCED DIABETES • MAY BE LIFE LONG • MAY ONLY NEED DIABETES MEDICATIONS WHILE ON GLUCOCORTICOIDS • HIGHER RISK OF HYPERGLYCEMIA AND REQUIRING MEDICATION LATER IN LIFE

  10. GLUCOCORTICOID THERAPY IN PATIENTS WITH DIABETES • PATIENT WITH PRIOR DIAGNOSIS OF DIABETES • INCREASE IN INSULIN RESISTANCE • DIABETES MEDICATIONS • INCREASE • CHANGE • HIGHER RISK OF COMPLICATIONS • SIDE EFFECTS

  11. FACTORS • OUTPATIENT SETTING • WHAT DRUG IS GIVEN • ROUTE GIVEN • TIME GIVEN • DOSE OF DRUG • HOW LONG IS THE TREATMENT • SHORT-TERM • LONG-TERM • UNKNOWN

  12. WHERE TO BEGIN? • TIME GLUCOCORTICOID IS GIVEN • WHEN IS HYPERGLYCEMIA OCCURING • FASTING • PRE-MEAL • POST MEAL • BEDTIME • DO CARBOHYDRATES/MEALS INCREASE HYPERGLYCEMIA

  13. WHAT MEDICATION TO GIVE? • ALWAYS DEPENDS ON THE PATIENT!! • USUALLY BEST TREATED WITH INSULIN • IF ALL BLOOD SUGARS (FSBS) ARE HIGH – BASAL INSULIN • IF ONLY POST MEAL FSBS ARE HIGH – BOLUS INSULIN • IF THERE IS A COMBINATION – BASAL & BOLUS INSULIN

  14. HOW MUCH? • ONCE AGAIN – DEPENDS ON PATIENT • START LOW DOSE • CAN ALWAYS INCREASE • DO NOT FEAR HYPOGLYCEMIA – TEACH PATIENT HOW TO TREAT AND RESPOND • HAVE PATIENT SEND IN FSBS RECORD

  15. Example • Pt has never been dx with Diabetes. • Has liver transplant – at that time HgA1c was 5.7%. • Several episodes of rejection. • Discharged from hospital on prednisone. Received insulin in hospital only. • Taking Prednisone 15mg at 9am and 10mg at 3pm

  16. Glucocorticoid Induced Diabetes Mellitus • Started Levemir 15 units to take with the Prednisone 15mg

  17. Saturday 11/13/10 5:15 am -  209 9:15 am after breakfast  - 282 11:45 am before lunch - 272 1:45 pm after lunch 385 6:15 pm before dinner - 348 8:15 pm after dinner 357 * Gave 15 units Levemir at 9:00am with Prednisone Sunday 11/14/10 7:00 am Before breakfast -185 9:00 am after breakfast - 304 12:00 noon - before lunch - 241 2:00 pm after lunch - 248 6:45pm before dinner - 248 8:45 pm after dinner - 259 *Gave 15 units Levemir at 9:00 am with Prednisone Monday 11/15/10 6:15am before breakfast - 142 (Ate at 8:15am - Lab day; drawn at 7:00 am at  Baptist Outpatient Lab) 10:15am - after breakfast - 224 12:00 noon before lunch - 247 2:00 pm after lunch - 371 6:45 pm before dinner - 241 8:45 pm - after dinner - 268 Gave Levemir 18 units at 9:00am with Prednisone

  18. 11/20/10 Fasting - 119 Before Breakfast - (had coffee) - 184 - 7u Novolog Before lunch - 186 - gave 7u Novolog After lunch 92 hours) - 191 Before Dinner - 161 - Gave 6u Novolog *Levemir - 18u at 9:00am 11/21/10 Fasting - 117 Before Breakfast (had coffee) - 178 - Gave 6u Novolog After breakfast (2 hours) - 306 - Tried Insulin in leg - didn't work?? Before lunch - 230 - gave 8u Novolog After lunch (2 hours) - 217 Before Dinner 173 - Gave 6u Novolog *Levemir - 18u at 9:00am 11/22/10 Fasting - 93 Before breakfast 9had coffee) - 121 - Gave 4u Novolog Before Lunch - 170 Gave 6u Novolog After lunch (2 hours) - 160 Before Dinner - 192 - Gave 7u Novolog * Gave Levemir 18u at 9:00 am 11/23/10 Fasting - 114 Before Breakfast (had coffee) - 175 - gave 6u Novolog

  19. Date    Fasting    Before Breakfast    2Hrs after breakfast    Before Lunch    2Hrs after Lunch    Before Dinner    2Hrs after Dinner 12/17    99              137                                                        129                                                93                    127 12/18    112            149                                                        109                     107                     100                     12/19    143            140                                                        164                                                105                   119 12/20    Lab            136                                                        121                       84                       97 12/21    104            118                        108                           119                                                 89 12/22    121            124                                                        124                                                  98                    84 12/23    131            131                                                        119                                                112                    98 12/24    107            123                                                        113                      107                    123 12/25    124            149                                                        132                      112                    118 12/26    117            120                        137                           125                                                131 12/27    Lab            146                                                         147                                               111                    96 I take 15u of Levemer at 9am daily with Prednisone and 5u of Novolog before each meal with adjustment of additional 1u/25 of BS over 100. 

  20. Next Example • Pt (76 yo, Pulmonary Fibrosis, COPD) dx in hospital with Type 2 DM • HgA1c 8.0% • Given IV Solumedrol and sent home on tapering prednisone • Sent home with directions for aspart (novolog) insulin and glipizide

  21. Currently taking glipizide 5mg daily • Maintenance dose Prednison 10mg daily

  22. Januvia 100mg daily

  23. AS THERAPY CONTINUES….. • GLUCOCORTICOIDS ARE TAPERED OR STOPPED = DIABETES MEDICATIONS NEED TO BE TAPERED OR STOPPED • BASE CHANGES ON MORE THAN ONE READING • STAY IN TOUCH WITH YOUR PATIENTS

  24. IMPORTANT! • Tell your patients to ALWAYS tell their provider who manages their diabetes about glucocorticoid therapy!!! Especially when started, stopped, or changed!!! • Depending on the patient, the provider may or may not make any changes. • Better to be safe than sorry! • EVERY PATIENT IS DIFFERENT!!

  25. REFERENCES • American Association of Clinical Endocrinologists • American Diabetes Association

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