Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review

Abstract

ObjectivesWhat is the most effective pharmacological intervention for glycaemic control in known type 2 diabetes mellitus (DM) without prior insulin treatment and newly started on systemic glucocorticoid therapy?DesignWe conducted a systematic literature review.Data sourcesWe searched MEDLINE, Embase and Cochrane Library databases and Google for articles from 2002 to July 2018.Eligibility criteriaWe combined search terms relating to DM (patients, >16 years of age), systemic glucocorticoids, glycaemic control, randomised controlled trials (RCTs) and observational studies.Data extraction and synthesisWe screened and evaluated articles, extracted data and assessed risk of bias and quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation guidelines.ResultsEight of 2365 articles met full eligibility criteria. Basal-bolus insulin (BBI) strategy for patients under systemic glucocorticoid therapy was comparatively effective but provided insufficient glucose control, depending on time of day. BBI strategy with long-acting insulin and neutral protamin Hagedorn as basal insulin provided similar overall glycaemic control. Addition of various insulin strategies to standard BBI delivered mixed results. Intermediate-acting insulin (IMI) as additional insulin conferred no clear benefits, and glycaemic control with sliding scale insulin was inferior to BBI or IMI. No studies addressed whether anticipatory or compensatory insulin adjustments are better for glycaemic control.ConclusionThe lack of suitably designed RCTs and observational studies, heterogeneity of interventions, target glucose levels and glucose monitoring, poor control of DM subgroups and low to moderate quality of evidence render identification of optimal pharmacological interventions for glycaemic control and insulin management difficult. Even findings on the widely recommended BBI regimen as intensive insulin therapy for patients with DM on glucocorticoids are inconclusive. High-quality evidence from studies with well-defined DM phenotypes, settings and treatment approaches is needed to determine optimal pharmacological intervention for glycaemic control.PROSPERO registration numberCRD42015024739.

Incidence and control of steroid-induced hyperglycaemia in hospitalised patients at a tertiary care centre for lung diseases

“…Low incidence of SIH (60/283 patients; 21.2%) in comparison with similar studies was identified [ 13 – 16 ]. However, only 168/283 patients had ≥ 2 BG readings performed during hospitalisation, and none of the patients had regular 4 times daily BG readings during GC treatment as suggested for patients with SIH [ 18 ].…”

“…The incidence of steroid-induced hyperglycaemia (SIH) is estimated to be around 40–50% [ 13 – 16 ]. Three types of SIH can be distinguished, namely exacerbation of an existing type 2 diabetes mellitus (DM), newly discovered DM, and transient hyperglycaemia in patients without pre-existing DM [ 17 , 18 ].…”

“…There are no general consensus guidelines for SIH management. Several studies have compared different insulin regimens providing mixed results [ 13 ]. Information regarding the use of oral hypoglycaemic agents mainly comes from small clinical trials and case studies [ 4 ].…”

Dulaglutide improves glucocorticoid-induced hyperglycemia in inpatient care and reduces dose and injection frequency of insulin

“…In patients initially treated with a medium-high dose of GC in the morning, as were the majority of patients in this study, the increased blood glucose level is detected mainly in the postprandial state and afternoon [16]. Consequently, an increased frequency of injections due to bolus and basal-bolus insulin treatment is often inevitable [17]. However, increased insulin injection frequency is reportedly associated with decreased patient QOL [9,10].…”

Safe care for people with diabetes in hospital

“…37,38 A recent systematic review suggested that there are little data to show which is the best management strategy for this condition, thus for individuals with variable intake, an insulin-based regimen may be the most appropriate strategy while in hospital. 39…”