Steroid Induced Diabetes Management

[ingemlb]

I thought to start this thread to specifically discuss diabetes but with a focus on steroid induced diabetes.
Within 3 days of starting Prednisolone in late January my sugar went out of control and I was diagnosed as steroid induced diabetic. I had been on and off diagnosed pre-diabetic but managed to control it with diet and the last few years blood tests had been in the normal range.

It was decided with my own input to start insulin injections. I didn't want to fiddle around for months trying to stabilise on some other oral drug living with the high hope that once the pred was reduced or even discontinued the diabetes would reverse itself. I also felt that as the pred was going to be adjusted continuously it would be easier to adjust the insulin than oral diabetic medication.

Only issue was that I was put on Novamix which controlled the highs but introduced too many lows for my liking. I was constantly worried about hypos especially during the night and early mornings. The insulin was reduced when the pred was reduced however that then made the sugar jump far too high in the afternoon/evenings.

I finally managed to get hold of an Endocrinologist who decided that in my case the novamix wasn't the best option. Something I had been wondering myself as I figure with normal fast acting Insulin I could be more in control. So I am now on Novarapid which I take 2x a day. 8 Units after I take the pred with my lunch and 6 units after dinner.

But it's a learning curve for me. So I am doing very frequent measuring of my blood sugar with the aim being to get it to as normal a level as possible. Having the instant insulin here also means I can now reduce my carb consumption. I was eating cake and carbs around the clock to avoid hypos. Not great for the waist.

The cake weaning was a bit harder than I thought. Also because I stuffed up on Tuesday and was 8 hours late with taking my pred hence everything was rather mucked up.

Wednesday was my last day on Novamix and due to the very late (8pm) intake of Pred my sugar jumped to an all-time high before bedtime
Thursday I was surprised that overnight it had dropped to 6.6 which is close to normal for fasting (should really be under 6)
Thursday lunchtime it was 6.3. I had Chicken casserole and rice for lunch. 30 mg Pred and 8 units of Novarapid.
Here is how the sugar behaved:
5am 6.6
1pm 6.3 (before eating lunch and taking pred)
2.30pm 9.4
6pm 17.9 (regarded dangerously high) - before dinner
9pm 15.0 (I was initially told I must try to keep it below 14 however as long as it keeps dropping the Endo was not too worried)
3am (Friday) 8.6
So I wasn't too worried it being day 1. I also know what drove it up so high after dinner. I had some cake as afternoon snack. Bad time of day
for me to eat cake as it was also on top of the rice for lunch.
Friday was as follows:
5am 7.0
1pm 6.5 (before lunch and pred)
6pm 16.9 (after dinner and 6 units of Insulin)
9pm 16.6
11:45pm 9.4
Same transgression. Had cake in the afternoon

Saturday I behaved myself.
5am 8.6
1pm 6.8
6pm 14.2 (after dinner and 6 units of Insulin)
8pm 17.7 Now I worried and decided to take 2 more units of Insulin
10pm 14.8

By Sunday (today) morning it was down to 6.7

Strange thing I found was that the sugar was higher in the evening when I didn't eat the cake in the afternoon. All I can think is that on both previous days instead of our usual soup we decided on a toasted chicken or ham sandwich made with wholegrain bread. But it must be the bread was too high in carbs. Not sure will be tracking this a bit longer. But I think when the sugar climbs above 14 I will simply take 2 Units of insulin or 4 if it is much higher.

Ringing the Endo early next week to discuss progress. He may decide to increase the novarapid both at lunchtime and dinner time.

Anyway, thought for anyone else totally new to diabetes management this may be useful information. The units we use in Australia are different to those used elsewhere when measure Blood Glucose. Here are the recommended values explained:
Fasting - if below 5.5 no diabetes; if between 5.6 and 6.9 could indicate pre-diabetic and needs more testing; If over 7 it's diabetes.
Non-Fasting - if below 5.5 no problem. if between 5.5 and 11 more testing could a) decide no diabetes or pre-diabetic . if over 11 and fasting glucose tolerance test shows up over 7 then it's definitely diabetes.
I was told at the hospital to sing out when the blood glucose goes over 14 after eating. So at the moment that is the guideline I am using. If it is constantly over 14 after lunch and dinner I should probably increase the insulin.

The great thing with novarapid is I can sleep at night without worrying about hypos and go out in the mornings without worrying about hypos. It will also be very easy now to adjust the units once the pred starts coming down again.

[annekat]

Very interesting and informative, Inge. My mother had the steroid induced diabetes and had to give herself insulin, but only for maybe a couple of months, after having pneumonia and being put on pred. No sign of this happening in me, yet, but reading your experience is enlightening in case it ever should. Those hypos sound awful. I'm sorry you have to go through this, but you are really taking it in stride and handling it intelligently, which I admire, and reporting on it in a way that will help others!

[ingemlb]

Well clever me!!! Today I wanted to get it TOTALLY RIGHT and avoided all cake. Had no bread for breakfast or lunch. Then got extremely hungry around 4pm so had a bit of cheese, a bit of salami and probably bad idea a tangelo. Before dinner BS was 14.8 and we had roast chicken, roast pumpkin and roast sweet potato and roast potato.

So I decided i would increase the insulin to 8 units instead of 6. Which I did. However I had a hard time pushing the needle down and then it got totally stuck on 2 units. I pulled it out and examined it and found that I had not screwed it on properly. funny enough I had not seen that when I primed it. So I screwed it tight and a big stream of insulin came spurting out. So now I don't know if any or none of it got into my system. I decided to take another 4 units and then check every 2 hours to see how it is going in case i need more

[drz]

In my experience managing my diabetes takes a lot more work and creates a lot more emotional strain than Wegs but learning to manage my diabetes was really good training to help me adjust to having Wegs. Hypos are a bad experience and can be very dangerous but the other extreme can also be too.

I rely on on my continuous glucose monitor to help me monitor both plus 8-10 finger stick readings a day and a 6-12 adjustments to my insulin pump to try keep blood glucose in a tolerable range. Is USA we usually similar numbers for our A1C levels which average blood glucose for past 60 days and I finally got my A1C level under 8 again for first time since I started on prednisone over four years ago because of Wegs. One can get normal or lower A1C levels by having many hypoglycemic episodes but this is very undesirable way to do so. My endo is more concerned with number of hypos than overall A1C levels.

My meters are calibrated for a 100 being normal desirable, 70-75 starting the hypo range, and anything over 250 getting dangerously high. I usually see both extremes most days but my endo is happy with my management given the fact i still take 5 mg of pred daily and most likely will continue to do so the rest of my life.

[chris.wg]

I was diagnosed as a diabetic in the hospital when I had my WG diagnosed. But I was barely over and knew it was coming family history and all. Within both parents immediate families out 8/12 with it. Plus I have helped manage a young lady with type 1. First question I have is are you snacking between meal. High protein style snack with a little carbs. I have been pure diet controlled for over a year now since getting off the pred the first time. I was on metformin before that. But what was explained to me is the mid meal snacks are needed to help regulate sugar. It actually helped a lot I use to find myself with spikes just before my dinner testing. When I started a mid day snack between lunch and dinner. Nothing high carb mostly cottage cheese or cheese or things like that it helped a lot. As for the lows I will warn you watch those CLOSE highs can do damage as everyone knows but lows are the danger because most people don't realize how dangerous they are. I have not looked into it but was told that low drops can actually kill brain cells. Maybe someone with more medical back ground then me can confirm this but was told this is due to the fact that sugars is the only thing that feeds our brain. But something my fathers doctor said to him why lows are extremely dangerous. For 2 different reasons both high and low can render you unconscious. When you are too high in most situations eventually you will come back to as your body disposes of the sugar. But if your to low its not like your taking food in. Still all and all I seriously suggest adding a higher protein snack between breakfast and lunch and between lunch and dinner.

[ingemlb]

Thanks Chris. Yes I was freaking out with the lows. Last year a young friend I had met online died during a hypo attack in her sleep. Hence my paranoia. I was having constant snacks between breakfast and lunch to avoid the lows and also before bed time and sometimes 3am in the morning.Some days even the snack was not enough and if I got distracted I would suddenly find myself shaking and sweating.

However now that I am off the novamix the lows are no longer a problem. I was only getting them because the novamix was releasing a constant stream of insulin into my body which I only needed to lower the sugar after taking the pred. Hence now I can control it quite well. Just have to be firm with myself. Since starting on the Novarapid I have never been below 6 so that's the lows gone. I now just need to get on top of the highs.

And thanks drz I can relate to the frequent finger stick exercises. I had the A1C test done recently and it came back 7.2 so my Rheumatologist said not perfect but better than lots. My Endo said should be lower. So will see what it says next time now I am on the new insulin. Mind you now that I read your post I am wondering if the 7.2 was thanks to the regular hypos!!!

Really appreciate your feedback

[Auntie TooToo]

Just now reading your post ... I too have been having the same problems with my blood sugar. For many yrs {prior to WG} I dealt with low blood sugar; then with the introduction of steroids to my daily regime it turned into full blown diabetes. At one point, mine were so high that my meter would not even register {but then I was on 120 mg daily of prednisone}. So my rheumy & pcp referred me to an Endo for consultation. He has been excellent, BS is getting better controlled; I'm on Metformin 1000 mg twice daily along with Lantus during the day & Novolog at bedtime. As my rheumy reduces the steroid dosage, my BS is lowering and we are tapering down on insulin's as well. Just have to continue monitoring, I notice that my afternoon sugars are usually the highest due to taking steroid in am. This is all such an adventure - WG {and the meds to treat} sure wrecks havoc on our bodies {not to mention our emotions}. Hang in there ..... this too shall end one day!

[ingemlb]

Thanks Tootoo Yes well Hypoglycemia is seen as pre-diabetic but I was luckily able to avoid the diabetes via strict diets. Now that I swapped to taking my pred in the Morning I too get that spike mid afternoon. Today I had to take 2 extra lots of insulin. Maybe it takes a few days for the body to adjust to the new routine.

[drz]

I have had diabetes for decades and was already on insuln pump and CGM (continuous glucose monitor) for years before my Wegs developed and was diagnosed. When in the nursing home for rehab work dafter my initial treatment for Wegs I remember my blood glucose levels often ranged from 400 plus in mornings and early afternoon to lows of 40 in early hours of AM when high does of pred wore off. I often had to have hourly checks of my blood glucose and snack several times every night. I would nap most of the time due to high levels of fatigue and having poor sleep most nights. Blood glucose levels improved slowly as my pred dosage was decreased and my insulin dosages in my pump were increased and tweaked to follow my blood glucose levels. I still need my Dexcom CGM to help monitor my highs and lows and to make adjustments on my insulin pump frequently throughout the day but I had my best A1C level last check up and finally got back to A1C levels I had my Wegs was diagnosed. I am still on 5 mg of pred which affects my blood glucose levels. Higher dosages create more problems.

[ingemlb]

Thanks for sharing drz. I am finding things still very confusing. I have now increased the Insulin in the morning to 24 Units (up from the initial 8 at lunchtime) and to 28 Units for lunch (up from 6 units with dinner). That seems to be so far the best I can manage to keep the blood glucose as normal as possible. However I find incredible swings. I can eat the same stuff each day and yet the BG levels are wildly different.

For instance I have a piece of fruit on waking. Sometimes it puts the blood glucose up by a very small amount, other times it goes up by at least double. Then yesterday I skipped the snack. My blood glucose was close to normal for fasting on waking and 3 hours later, without eating anything at all it had climbed up quite a bit. I had one cup of herbal coffee substitute with a bit of milk but I have that with the fruit every morning so I simply can't explain the rise in levels apart from stress. Also I have been going down with the pred but needing to go up with the insulin. But then we have had the most stressful couple of weeks in ages with our son having his psychotic episode and that most likely is affecting not only the wegener's but also the diabetes I am assuming.

I now have a referral to a Nurse diabetic educator. Will have to make an appointment. Too many appointments already this week so will have to wait until I can catch my breath next week