Steroid Induced Diabetes Early Detection Treatment and Management

What is Steroid Induced Diabetes?
Steroid Induced Diabetes -A Wake-Up Call! Picture this world from 200 years ago when a simple gash on the leg seemed life-threatening, for it might develop gangrene or sepsis. The terror of many diseases has now been erased from the memory of humanity due to the advent and development of Steroids medications, and treatments. What earlier The other side used to be a battle of life and death, today is of the Wonder only a pill away from cure. We happily take Drugs medicines sighing in the relief that they bring us without little thought into what we are actually consuming. Before a drug is brought into public use, it undergoes rigorous clinical trials to prove its safety for human consumption. However, these drugs prove to be potent when used during necessity, but can also be double-edged.

Steroids, a class of drugs, are commonly used for suppressing inflammatory reactions in the disorders of immune system. They ease painful symptoms and make otherwise incurable disease more manageable. In spite of steroids being highly effective in treatment of some diseases, their long-term high dosage have long corticosteroids, lasting negative effects on the body, including development of type 1 diabetes.

What are the uses of steroids?
Most of the sex ovarian hormones in our body such as androgen, progesterone and estrogen, as well as corticosteroids (mineralocorticoids and glucocorticoids) released by adrenal glands are Steroid Hormones. These hormones are derived from cholesterol and are synthesized in the body as needed since they cannot be stored in the cells for long. The steroid based medications, that are commonly prescribed, are synthetic forms of these hormones and are given to manage inflammatory reaction that occurs in autoimmune disorders and others. These drugs are corticosteroids, of which glucocorticoids are most commonly used.

Corticosteroids are different from the anabolic steroids that are used for building up muscle mass. Generally, glucocorticoids are used for managing a large number of disorders like Asthma, Gout, Allergy, Rheumatoid Arthritis, Inflammatory Bowel Disease, Multiple Sclerosis and in pregnancy for Fetal Lung Maturation. Corticosteroids act by switching off genes involved in the inflammatory reaction, thus, suppressing the effects. At higher concentrations, they can even activate the expression of anti-inflammatory genes.

However, the many benefits of corticosteroids are offset by several adverse effects if glucocorticoids are taken in high doses for a long period of time.
What are the side effects of steroids?
The side effects of steroids are as below:

• Osteoporosis
• Abdominal obesity
• Growth retardation in children
• Glaucoma
• Cataracts
• Neurosis
• Hypertension
• Diabetes
• Development of drug resistance

How does steroid induced diabetes happen?
Diabetes Mellitus (DM) is a complication of glucocorticoid use and is associated with an abnormal increase in blood glucose level. This includes both the exacerbation of hyperglycemia in diabetic patients, as well as causing DM in patients without hyperglycemia before initiation of glucocorticoid therapy. Hyperglycemia may be transient in most cases but some patients may develop other symptoms associated with diabetes like polydipsia and polyuria, as well as glucose levels do not normalize after discontinuation. The end effect of this may be serious leading to elevated risk of cardiovascular disease and even coma in elderly patients. Patients who have received transplantation are given corticosteroids for immune suppression to prevent graft rejection. In such patients new onset diabetes after transplant is a strong predictor of graft failure. Currently, there is a paucity of data on the exact prevalence of steroid induced diabetes making it a challenge for medical practitioners.

What is the mechanism of action of glucocorticoids?
After long term use of glucocorticoids, there is development of insulin resistance and dysfunction of beta cells of pancreas which gives rise to Hyperglycemia. They act on the adipose (fat) tissue and liver cells to control the pathways involved in fatty acid release and uptake from the blood. Their net effect is to increase the amount of fatty acids in the bloodstream, which interferes with the uptake of glucose by cells in the body. This leads to the development of insulin resistance in tissues, particularly in the skeletal muscle Insulin resistance in turn increases production of glucose (gluconeogenesis) by the liver while simultaneously lowering uptake of glucose by tissues from the bloodstream. Corticosteroids also increase glucose production directly by activating genes involved in the metabolism of carbohydrates in liver, leading to increased gluconeogenesis.

What are the risk factors for development of Steroid induced Diabetes Mellitus?

• Older age
• High BMI
• Impaired glucose tolerance prior to initiation of therapy
• Dosage of the medication
• Duration of medication course

However, glucose tolerance is normally seen to decline with age and obesity, decreased physical activity, and common use of medications is also more often seen in elderly patients. This makes older age the only apparent independent risk factor for SDM. In addition to these, other suspected risk factors include concurrent use of other immune-suppressive agents, low serum magnesium levels, liver disease such as Hepatitis C virus infection.

The symptoms common to diabetes such as increased thirst and increased urination after taking corticosteroids can be indicative of SDM and should prompt an assessment of blood glucose, ideally after 4 to 6 hours of taking the medication. Diabetic ketoacidosis which is a common complication of type 1 DM has also been reported in patients with diabetes who receive glucocorticoids and they should hence be monitored carefully. Steroids can precipitate diabetic ketoacidosis and this may occur in absence of any other triggering factor, and even in patients with type 2 DM that is well under control.

How do you know if you have steroid induced diabetes?
Considering that corticosteroids are some of the most commonly used medications in the world, it is no surprise that Steroid induced Diabetes Mellitus is a rather common occurrence and glucocorticoid induced diabetes is the most common cause of drug-induced diabetes.

Steroid induced Diabetes Mellitus, in more serious cases, can lead to hyperglycemia that may require hospitalization or become a medical emergency. Further, high glucose level in blood increases the risk of infections and leads to other complications and comorbidities. Anticipating and detecting SDM early is hence essential to improve patient outcome.

The diagnostic procedure for Steroid induced Diabetes Mellitus is similar to that of other types of diabetes. Prior to beginning the glucocorticoid treatment, patients should be warned to look out for the common symptoms of diabetes and to seek blood sugar test if symptoms are seen. A glucose level higher than 200 mg/ml one to two hours after lunch (as glucocorticoids do not affect fasting glucose levels) should be further investigated.

In the absence of symptoms, HbA1c, fasting plasma glucose or oral glucose tolerance test may be used, and the results confirmed with repeat testing. Blood glucose should also be monitored for non-diabetic patients but who at high risk for developing Steroid induced Diabetes Mellitus. Oral glucose tolerance test can allow early detection diabetes in highrisk patients. In patients where HbA1c levels could be unreliable, fructosamine level testing can be done.

How is steroid induced diabetes treated and managed?
Management of Steroid induced Diabetes Mellitus is based on controlling hyperglycemic episodes in patients who have taken glucocorticoids. Frequent fluctuations in blood sugar levels are associated with increased risk of mortality. The therapeutic measures should be progressive and additive with emphasis on selection of those hypoglycemia drugs that work with the pathophysiology of Steroid induced Diabetes Mellitus and with the patient's hyperglycemia profile. Since, these patients are already on medications for treatment of other diseases, or have recently undergone transplantation, drug interactions between these medications should be taken into consideration.

Oral hypoglycemic drugs are prescribed for treatment of milder forms of Steroid induced Diabetes Mellitus. The oral hypoglycemic drugs which can be given for Steroid induced Diabetes Mellitus should have a rapid action onset, with preference given to those that can reduce postprandial glucose. insulin sensitizers as well as insulin itself may also be prescribed for treatment of Steroid induced Diabetes Mellitus.

The main focus of managing Steroid induced Diabetes Mellitus is controlling blood glucose level. In addition to the hypoglycemic drugs, healthy lifestyle measures may also be implemented. However, these should be done under guidance from a medical counselor because of the condition for which the glucocorticoid was prescribed.

Despite Steroid induced Diabetes Mellitus being a frequent unwanted effect of corticosteroid usage, its exact mechanisms are not well known. The diagnostic and treatment procedures are not standardized, but are rather tailored based on the dosage of the drug given and the patient's profile. Better understanding of Steroid induced Diabetes Mellitus and an increased awareness about its existence in patients taking steroid medications are essential to recognize Steroid induced Diabetes Mellitus early and initiate glucose regulating treatment at the earliest.