Corticosteroid-induced hyperglycemic crisis

Crisis hiperglucémica inducida por corticoides

Introduction: a hyperglycemic crisis is the most serious acute complication of diabetes mellitus (DM). Precipitating factors are usually infection, intoxication, inflammation, ischemia and iatrogenesis. The latter refers to the intake of drugs such as glucocorticoids, since it is paradoxical that being hyperglycemia, one of the best-known side effects, it is one of the most underestimated. Case presentation: 62-year-old woman with a personal history of idiopathic thrombocytopenic purpura treated with 50 mg of prednisolone a day, who was admitted to the emergency room for presenting somnolence, asthenia and hyporexia, since the last 5 days. Somnolence, grade III dehydration, ketonuria and a 320.48 mOsm/kg urine osmolality, blood glucose level of 1.035 mg/dL and arterial blood gases indicating uncompensated metabolic acidosis, were found. The case was considered a mixed hyperglycemic crisis probably induced by corticosteroids. Insulin therapy and IV hydration were provided with favorable progression. Discussion: glucocorticoids feature multiple adverse manifestations, among which the deleterious effect on carbohydrate metabolism stands out, which may not only exacerbate hyperglycemia in known diabetics, but also facilitate the appearance of DM in patients without a prior diagnosis. Conclusion: establishing the incidence of patients with autoimmune diseases treated with corticosteroids, who develop diabetes mellitus, is required.

1. Urquizo Ayala G, Arteaga Coariti R. Diabetes e hiperglicemia inducida por corticoides. Rev. Méd. La Paz, 2017; 23(1):60-68.
2. Roberts A, James J, Dhatariya K. Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group. Diabet Medi. 2018;35(8):1011–1017. https://doi.org/10.1111/dme.13675.
3. Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019;365:l1114. https://doi.org/10.1136/bmj.l1114.
4. Agudo-Tabuenca A, Gimeno-Orna JA, Sáenz-Abad D. Assessment of the efficacy and safety of a protocol to manage glucocorticoid-induced hyperglycemia in diabetic patients during hospital stay. Endocrinol Diabetes Nutr (English Ed). 2019;66(6):353–360. https://doi.org/10.1016/j.endien.2019.01.008
5. Cooper N, Ghanima W. Immune Thrombocytopenia. N Engl J Med. 2019;381(10):945-955. https://doi.org/10.1056/NEJMcp1810479.
6. Radhakutty A, Burt MG. MANAGEMENT OF ENDOCRINE DISEASE: critical review of the evidence underlying management of glucocorticoid-induced hyperglycemia. Eur J Endocrinol. 2018;179(4):R207-R218. https://doi.org/10.1530/EJE-18-0315.
7. Koorneef LL, van der Meulen M, Kooijman S, Sánchez-López E, Scheerstra JF, Voorhoeve MC, et al. Dexamethasone-associated metabolic effects in male mice are partially caused by depletion of endogenous corticosterone. Front Endocrinol (Lausanne). 2022;13:960279. https://doi.org/10.3389/fendo.2022.960279.
8. Agudo-Tabuenca A, Gimeno-Orna JA, Sáenz-Abad D. Assessment of the efficacy and safety of a protocol to manage glucocorticoid-induced hyperglycemia in diabetic patients during hospital stay. Endocrinol Diabetes Nutr (English ed.). 2019;66(6):353-360. https://doi.org/10.1016/j.endinu.2019.01.008.
9. Mader JK, Brix JM, Aberer F, Vonbank A, Resl M, Hochfellner DA, Ress C, Pieber TR, Stechemesser L, Sourij H. [Hospital diabetes management (Update 2023)]. Wien Klin Wochenschr. 2023;135(Suppl 1):242-255. https://doi.org/10.1007/s00508-023-02177-5.
10. Lo C, Toyama T, Oshima M, Jun M, Chin KL, Hawley CM, Zoungas S. Glucose-lowering agents for treating pre-existing and new-onset diabetes in kidney transplant recipients. Cochrane Database Syst Rev. 2020;8(8):CD009966. https://doi.org/10.1002/14651858.CD009966.pub3.
11. Tous Lopera R, Coy Barrera AF, Rojas García W. Hyperglycemia Induced by Glucocorticoids on Hospitalized Patient: Approach and Management. Revista Colombiana de Endocrinología, Diabetes y Metabolismo. 2019;6(1):55–61. https://doi.org/10.53853/encr.6.1.469.
12. Keyßer G. [Safety aspects of the treatment with glucocorticoids for rheumatoid arthritis]. Z Rheumatol. 2021;80(4):295-304. https://doi.org/10.1007/s00393-021-00972-x.
13. Sudlow A, O’Connor HM, Narwani V, Swafe L, Dhatariya K. Assessing the prevalence of dexamethasone use in patients undergoing surgery, and subsequent glucose measurements: a retrospective cohort study. Pract Diab 2017;34(4):117-121. https://doi.org/10.1002/pdi.2098.
14. Uchihara M, Bouchi R, Kodani N, Saito S, Miyazato Y, Umamoto K, Sugimoto H, et al. Impact of newly diagnosed diabetes on coronavirus disease 2019 severity and hyperglycemia. J Diabetes Investig. 2022;13(6):1086–1093. https://doi.org/10.1111/jdi.13754.
15. Lhakani OJ, Kumar S, Triphati S, Desai M, Seth C. Comparison of two protocols in the management of glucocorticoid-induced hyperglycemia among hospitalized patients. Indian J Endocrinol Metab. 2017;21(6):836-844. https://doi.org/10.4103/ijem.IJEM_226_17.
16. Li J-X, Cummins CL. Fresh insights into glucocorticoid-induced diabetes mellitus and new therapeutic directions. Nat Rev Endocrinol. 2022;18(9):540–557. https://doi.org/10.1038/s41574-022-00683-6.
17. Deutsch AJ, Schroeder PH, Mandla R, Kang S, Erenler F, Mercader JM, Udler MS, Florez JC, Brenner LN. Type 2 Diabetes Polygenic Score Predicts the Risk of Glucocorticoid-Induced Hyperglycemia in Patients Without Diabetes. Diabetes Care. 2023;46(8):1541-1545. https://doi.org/10.2337/dc23-0353.
18. Elena C, Chiara M, Angelica B, Chiara MA, Laura N, Chiara C, Claudio C, Antonella F, Nicola G. Hyperglycemia and Diabetes Induced by Glucocorticoids in Nondiabetic and Diabetic Patients: Revision of Literature and Personal Considerations. Curr Pharm Biotechnol. 2018;19(15):1210-1220. https://doi.org/10.2174/1389201020666190102145305.
19. Wallace MD, Metzger NL. Optimizing the Treatment of Steroid-Induced Hyperglycemia. Ann Pharmacother. 2018;52(1):86-90. https://doi.org/10.1177/1060028017728297.
20. Hurtado Helard AM, Gil-Olivares FE, Castillo-Bravo L, Perez-Tazzo L, Campomanes-Espinoza GC, Aliaga-Llerena K, et al. Manejo de las crisis glucémicas en pacientes adultos con diabetes mellitus: guía de práctica clínica basada en evidencias. Rev. Fac. Med. Hum. 2021;21(1):50-64. http://dx.doi.org/10.25176/rfmh.v21i1.3194.