The Glucose Gamble: which steroid dosage is a better bet in diabetics?

Authors: Val Haddon, DPM¹, Malisha Pahari DPM², Balaj Chaudhry DPM³, Andra Achim DPM⁴

¹ Residency Director, HCA Florida Oak Hill Podiatric Medicine and Surgery, ²⁻⁴ Resident, Podiatric Medicine and Surgery HCA Florida Oak Hill Hospital

Purpose

  • Evaluate and compare blood glucose variations in diabetic patients taking either a fixed dose of 8mg methylprednisolone or the tapering-dose Medrol Dosepak daily.
  • We hypothesize that the Medrol Dosepak will cause a greater increase in blood glucose levels in comparison to the 8mg Methylprednisolone.

Literature Review

  • Corticosteroids can induce hyperglycemia, which in turn can lead to increased morbidity and mortality.
  • The development of corticosteroid-induced hyperglycemia and diabetes may be dependent on the duration of the treatment course. Lower dosage used for longer durations may be associated with hyperglycemia, suggesting that the effect may be dose cumulative.
  • Corticosteroid use has been associated with numerous side effects, including steroid-induced hyperglycemia and steroid-worsened diabetes.
  • Methylprednisolone 4mg/day does not stimulate the HPA axis.

Method

  • Single-center, prospective study.
  • N=15 for Methylprednisolone group, N=15 for Medrol Dosepak.
  • Provider prescribed Methylprednisolone 8mg for 6 days and monitor blood glucose levels daily.
  • Provider prescribed Medrol Dosepak 4mg for 6 days and monitor blood glucose levels daily.
  • All patients were given a blood sugar logging sheet and were asked to log their sugar daily and bring back the log on their next follow up appointment.
  • Advised patients to stop taking the steroids if they experienced substantial increase in their blood sugar levels.

Data & Images

Figure A: Graphical representation of average blood glucose level increase in % between Medrol Dosepak and Methylprednisolone.

Figure B: Methylprednisolone

Figure C: Medrol Dosepak

Discussion

  • Corticosteroids, including methylprednisolone, are commonly prescribed for their potent inflammatory properties. However, they can induce hyperglycemia with a concerning reputation with a lack of guidance or those at risk of glucose intolerance.
  • As hypothesized, our results demonstrated a significantly greater increase in blood glucose in patients receiving the tapered Medrol Dosepak compared to those on a fixed-dose Methylprednisolone regimen.
  • Average increase in blood sugar level in Methylprednisolone 8mg was 12%, but Medrol Dosepak was 30%. The Medrol 8mg does not increase blood glucose at the beginning, but then it averages out, but the Medrol Dosepak peaked at day 5.
  • Observed differences can likely be attributed to the pharmacokinetics and dosing pattern of the Medrol Dosepak. The tapering nature of the steroid releases a dose of a fast-acting corticosteroid, potentially causing greater fluctuations in glycemic control. In contrast, the fixed daily dose of methylprednisolone may maintain more stable corticosteroid levels, resulting in a less pronounced effect on blood glucose.
  • Limitations: Single-center study, smaller population, patient reporting compliance.
  • These findings could help raise awareness about which steroids may require more rigorous glucose monitoring.

Conclusion

  • Our study highlights the need for tailored corticosteroid regimens in diabetic patients. Medrol Dosepak, while effective for its indications, possesses a greater risk of hyperglycemia compared to a fixed 8mg dose of Methylprednisolone.
  • Health care providers should weigh these risks when selecting corticosteroid treatments and implement strategies to minimize adverse glycemic effects.

References

  1. Tsai, C., Lin, J., et al. (2000). “The Clinical Efficacy of different types of oral steroids on systemic corticosteroid capillary blood glucose levels of hospitalized patients with well-controlled diabetes.” Clinical Endocrinology & Metabolism, 85(4): 1761–1766. DOI: 10.1210/jcem.85.4.6548.
  2. Dehneva, N., Miller, N., Graham, S., et al. (2016). “Effectiveness and control of steroids-induced hyperglycemia in hospitalized patients with chronic disease.” Journal of Clinical Pharmacy and Therapeutics, 41(3): 331–337. DOI: 10.1111/jcpt.12351.
  3. American Diabetes Association. (2019). “Diabetes Mellitus and the Use of the Glucocorticoids in the Diabetic Patient Group.” Management of hyperglycemia and steroid-induced hyperglycemia in hospitalized patients with diabetes. Diabetes Care, 42(S1): S115–S128. DOI: 10.2337/dc19-S005.

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliate. The views expressed in this publication are those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.