Responsible Use of Oral Corticosteroids in People with Comorbid Diabetes: An Indian Expert Consensus

Comorbidities and intercurrent illnesses in people with diabetes may necessitate the use of steroids. Steroids cause or increase the risk of hyperglycemia, weight gain, dyslipidemia, hypertension, and CVDs, including heart failure in diabetes patients, the latest expert consensus has stated.

To address the inconsistencies in this clinical arena due to the lack of specific standard guidelines, the consensus working group (CWG) formulated a unified consensus for responsible steroid use in people with diabetes.

The expert consensus noted that Deflazacort is an effective and safe steroid with lesser risks of complications. Given its better safety, it can be considered one of the initial choices for people with diabetes requiring steroids.

The expert consensus released by the consensus working group (CWG) is published in the July 2024 issue of the Journal of the Association for Physicians of India.

The authors emphasize that there are no specific guidelines or consensus on the appropriate use of steroids in individuals with preexisting diabetes. To address this gap, the Consensus Working Group (CWG) has developed the Indian expert consensus for the rational use of oral steroids in people with diabetes. This consensus was reached through the nominal group technique, facilitating direct expert interaction. The group discussed various consensus topics during a meeting to formulate specific recommendations.

Some of the key summaries of expert consensus statements include the following:

Endocrine and Metabolic Complications:

• Hyperglycemia and DKA (Diabetic Ketoacidosis): Steroid use in individuals with diabetes can lead to hyperglycemia and may trigger DKA in susceptible individuals.
• Weight Gain: Weight gain is a common side effect of steroid therapy in people with diabetes and is directly related to both the dosage and duration of the treatment.
• Adrenal Effects: Discontinuing steroids in individuals with diabetes can result in adrenal insufficiency (AI), although the dosage or duration of steroid use does not influence this. Additionally, iatrogenic Cushing’s syndrome is a potential risk, which increases with higher steroid doses.

Cardiovascular Complications:

• Dyslipidemia, Hypertension (HTN), and Cardiovascular Risk: Steroids can induce or worsen hypertension and dyslipidemia in individuals with diabetes. The risk of cardiovascular diseases is elevated even with prednisolone doses less than 5 mg per day.
• Heart Failure (HF): Steroids may trigger heart failure in people with diabetes, so it's important to consider the mineralocorticoid effects of steroids in these patients.

Immunological Complications & Drug Interactions:

• Infections: Steroids can elevate the risk of bacterial, viral, and fungal infections in individuals with diabetes.
• Wound Healing: Steroids may impair wound healing in people with diabetes, particularly those with foot ulcers, requiring caution.
• Acne: Steroids can increase the likelihood of acne in individuals with diabetes, especially at higher doses or in the presence of predisposing factors such as high steroid dosage, application of steroid with occluded patch, age below 30 years, and history of acne.
• Drug Interactions: Steroids may interact with certain antimicrobials and other medications in people with diabetes. Monitoring for systemic toxicity is essential when using steroids alongside these drugs.

Musculoskeletal Complications

• Myopathy: Steroids can elevate the risk of myopathy in individuals with diabetes, with symptoms potentially appearing early, especially at higher doses.
• Osteoporosis and Bone Fractures: Steroid use in people with diabetes raises the risk of osteoporosis, even at doses of 5 mg or more of prednisolone equivalent. The risk of osteoporosis and associated bone fractures increases with the duration of steroid therapy.
• Avascular Necrosis: Steroids may heighten the risk of avascular necrosis of the femur in people with diabetes, with the likelihood increasing with higher steroid doses.

Ophthalmological Complications

• Cataracts and Glaucoma: In individuals with diabetes, steroids elevate the risk of cataracts, with the risk increasing with more prolonged use. Steroids may also raise the risk of developing glaucoma.

Recommendations on Complications Monitoring & Management:

The expert consensus advises personalized monitoring for early detection and treatment of complications in people with diabetes starting long-term steroids.

For glycemia, individualized plans are recommended, considering factors like glycemic status, medication use, age, and DKA risk, with more frequent continuous glucose monitoring during the first week of steroid therapy.

They recommend monitoring lipid profiles one month after starting treatment, then every 6-12 months, with more frequent checks for those with preexisting dyslipidemia. They recommend screening for signs of muscle damage at each clinical visit for musculoskeletal monitoring. In children, bone mineral density (BMD) should be assessed at 3 months and 1 year after starting steroids, while adults should have BMD evaluated at 1 year. Additionally, baseline assessments for cataracts and intraocular pressure for glaucoma are advised.

Steroid Equivalence and Appropriate Selection of Steroids

• The consensus statement favored an individualized approach while managing steroids’ caused complications in diabetes.
• Experts suggested “steroid equivalence” in routine clinical practice appropriately to avoid underdosing or overdosing when shifting from one steroid to another steroid. (Table 1 presents the dose-equivalent potencies of various corticosteroids)
• It is recommended to consider Deflazacort as the initial choice for diabetes patients requiring steroid therapy because of its favorable safety profile and effectiveness. Deflazacort is associated with fewer complications compared to other steroids. Below is the summary capturing the globally approved indications of Deflazacort (see Table 2).
• The consensus statement recommends modifications and/or the addition of newer agents to the existing antihyperglycemic drugs based on the severity of hyperglycemia and the pharmacodynamic action of steroids for managing steroids-induced hyperglycemia.

Table 1: Dose to dose steroid equivalence of different corticosteroids

Table 2: Approved indications of DFZ from the United States, United Kingdom and India.

Reference: Saboo, Banshi et al. “Responsible Use of Oral Corticosteroids in People with Comorbid Diabetes: An Expert Consensus.” The Journal of the Association of Physicians of India vol. 72,7 (2024): 79-93. doi:10.59556/japi.72.0573