Assessment of the Effectiveness of a Protocol to Manage Dexamethasone-Induced Hyperglycemia Among Hospitalized Patients With COVID-19

Optimal initial insulin dosage for managing steroid-induced hyperglycemia in hospitalized COVID-19 patients: A retrospective single-center study

Objectives

To determine the optimal initial insulin dosage for controlling hyperglycemia in COVID-19 patients receiving steroids, an area with limited data.

Methods

We retrospectively analyzed 156 COVID-19 patients with steroid-induced hyperglycemia treated with insulin. Patients were categorized by their total daily dose of subcutaneous insulin therapy when starting dexamethasone ⩾6 mg/day or equivalent dose of glucocorticoid: Group A (⩽0.29 units/kg), Group B (0.3-0.49 units/kg), Group C (0.5-0.69 units/kg), and Group B (⩾0.7 units/kg). Treatment failure was defined as mean blood glucose level > 280 mg/dL for two consecutive days after initiating insulin or any blood glucose ⩾ 400 mg/dL.

Results

The mean age was 64 ± 14 years, with 50% male, and a mean body mass index of 26.9 ± 6.9 kg/m2. Most had preexisting type 2 diabetes (62%). Mean admission blood glucose and HbA1c were 233 ± 112 mg/dL and 7.8 ± 2.3%, respectively. Group A had the lowest HbA1c (6.7 ± 1.2%), while group D had the highest (9.8 ± 2.5%). Median daily dexamethasone dosage or equivalent was 36 (IQR 16.72) mg, with no significant differences in among groups. Group A had the lowest treatment failure rate. There were no significant differences in treatment failure rate between Groups B, C, and D. Additionally, there were no statistically significant differences in mean BG across the groups: Group A 232 ± 42 mg/dL, Group B 247 ± 57 mg/dL, Group C 247 ± 61 mg/dL, and Group D 227 ± 67 mg/dL (p = 0.2). Group D had a significantly higher rate of level 1 hypoglycemia (p = 0.008), while no differences in clinically significant hypoglycemia (level 2 or 3) were observed between groups.

Conclusions

Among patients requiring TDD ⩾ 0.3 units/kg/day, there was no significant difference in treatment failure rate between Groups B, C, and D. Group D had the highest rate of level 1 hypoglycemia. This initial insulin dosage for hospitalized COVID-19 patients on high-dose steroid therapy should be personalized.

A Novel Algorithm for the Management of Inpatient COVID-19 Glucocorticoid-Induced Hyperglycemia

Hyperglycemia in hospitalized patients with coronavirus disease 2019 (COVID-19) is linked to increased morbidity and mortality. This article reports on a novel insulin titration protocol for the management of glucocorticoid-induced hyperglycemia in hospitalized patients with COVID-19. Sixty-five patients with COVID-19 and glucocorticoid-induced hyperglycemia admitted after the protocol implementation were matched 1:1 to patients admitted before the treatment protocol rollout for analysis. In a large, diverse health system, the protocol achieved reductions in hypoglycemic events without increasing hyperglycemia or insulin use.

Dexamethasone use and insulin requirements in coronovirus-19 (COVID-19) infection stratified by Hemoglobin A1c

Aims

The study aimed to identify weight-based insulin requirements for dexamethasone-induced hyperglycemia in COVID-19 infection stratified by hemoglobin A1c (HbA1c).

Methods

This retrospective study assessed hospitalized patients ≥ 18 years admitted with COVID-19 and receiving ≥ 1 dose of dexamethasone 6 mG. Daily blood glucose (BG) and insulin doses were collected and organized by HbA1c.

Results

Among 45 patients with available HbA1c, 100% [HbA1c ≥ 7%] and 72% [HbA1c < 7%] developed hyperglycemia (BG ≥180 mG/dL). Median daily insulin (Interquartile Range) (units/kG/day) was 0.03 (0, 0.32) [HbA1c 6–6.9%], 0.1 (0.06, 0.36) [HbA1c 7–7.9%], 0.66 (0.39, 0.69) [HbA1c 8–8.9%], and 0.72 (0.63, 0.78) [HbA1c ≥ 9%]. On day 10 of dexamethasone, when majority of patients were at goal BG, patients required 0.07 (0.01, 0.31) [HbA1c 6–6.9%], 0.59 (0.11, 0.75) [HbA1c 7–7.9%], 1.15 (0.95, 1.35) [HbA1c 8–8.9%], and 1.14 units/kG/day [HbA1c ≥ 9%]. Of 24 patients completing 10 days of dexamethasone, 25% experienced hypoglycemia (BG < 70 mG/dL) upon discontinuation.

Conclusion

Patients with higher HbA1c experienced greater dexamethasone-induced hyperglycemia and required higher insulin doses. Inpatient insulin dosing algorithms should take into consideration baseline HbA1c to avoid delays in achieving normoglycemia.

Dexamethasone-induced hyperglycaemia in COVID-19: Glycaemic profile in patients without diabetes and factors associated with hyperglycaemia

AIMS

To evaluate glycaemic profiles of COVID-19 patients without diabetes receiving dexamethasone and determine factors associated with hyperglycaemia.

METHODS

All subjects without pre-existing diabetes receiving dexamethasone 6 mg for COVID-19 in a non-critical care setting were identified. Glucose profiles were obtained from capillary blood glucose (BG). Univariate and multivariate analyses were performed to identify factors associated with dexamethasone-induced hyperglycaemia (BG ≥ 10 mmol/L).

RESULTS

Of 254 subjects, 129 (50.8%) were male with age 51.1 ± 18.2 years and weight 89.7 ± 26.3 kg. Hyperglycaemia post-dexamethasone occurred in 121 (47.6%). Glucose excursions began within three hours (6.8 ± 1.4 mmol/L pre-dexamethasone vs 8.7 ± 2.4 mmol/L at ≤ 3 h, p < 0.001) and peaked at 7-9 h (10.5 ± 2.3 mmol/L, p < 0.001 vs pre-dexamethasone). BGs post-intravenous were higher than post-oral administration for the initial six hours. Hyperglycaemic subjects were older (57.8 ± 17.5 years vs 45.0 ± 16.6 years, p < 0.001), had higher initial glucose (6.3 ± 1.0 vs 5.9 ± 0.9 mmol/L, p = 0.004), higher HbA1c (5.8 ± 0.3% [40 ± 3.5 mmol/mol] vs 5.5 ± 0.4% [37 ± 4.1 mmol/mol], p < 0.001) higher C-reactive protein (CRP) (100 ± 68 vs 83 ± 58 mg/L, p = 0.026), and lower eGFR (79 ± 17 vs 84 ± 16 mL/min/1.73 m², p = 0.045). Mortality was greater in the hyperglycaemia group (9/121 [7.4%] vs 2/133 [1.5%], p = 0.02). Age, HbA1c and CRP were independently associated with hyperglycaemia.

CONCLUSIONS

Half of subjects without diabetes experienced hyperglycaemia post-dexamethasone for COVID-19, peak occurring after 7-9 h. Age, HbA1c and CRP were associated with hyperglycaemia.

Glucocorticoid-Induced Hyperglycemia Including Dexamethasone-Associated Hyperglycemia in COVID-19 Infection: A Systematic Review

OBJECTIVE

Optimal glucocorticoid-induced hyperglycemia (GCIH) management is unclear. The COVID-19 pandemic has made this issue more prominent because dexamethasone became the standard of care in patients needing respiratory support. This systematic review aimed to describe the management of GCIH and summarize available management strategies for dexamethasone-associated hyperglycemia in patients with COVID-19.

METHODS

A systematic review was conducted using the PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases with results from 2011 through January 2022. Keywords included synonyms for "steroid-induced diabetes" or "steroid-induced hyperglycemia." Randomized controlled trials (RCTs) were included for review of GCIH management. All studies focusing on dexamethasone-associated hyperglycemia in COVID-19 were included regardless of study quality.

RESULTS

Initial search for non-COVID GCIH identified 1230 references. After screening and review, 33 articles were included in the non-COVID section of this systematic review. Initial search for COVID-19-related management of dexamethasone-associated hyperglycemia in COVID-19 identified 63 references, whereas 7 of these were included in the COVID-19 section. RCTs of management strategies were scarce, did not use standard definitions for hyperglycemia, evaluated a variety of treatment strategies with varying primary end points, and were generally not found to be effective except for Neutral Protamine Hagedorn insulin added to basal-bolus regimens.

CONCLUSION

Few RCTs are available evaluating GCIH management. Further studies are needed to support the formulation of clinical guidelines for GCIH especially given the widespread use of dexamethasone during the COVID-19 pandemic.

Impact of newly diagnosed diabetes on coronavirus disease 2019 severity and hyperglycemia

AIMS/INTRODUCTION

Diabetes is associated with poor clinical outcomes of coronavirus disease 2019 (COVID-19). However, the impact of newly diagnosed diabetes on prognosis has not been clarified. The objective of this study was to show the features and outcome of COVID-19 patients with newly diagnosed diabetes in Japan.

MATERIALS AND METHODS

We retrospectively analyzed 62 patients with diabetes hospitalized for COVID-19 between 1 April and 18 August 2021 at the National Center for Global Health and Medicine in Tokyo, Japan. We evaluated the worst severity of COVID-19 and plasma blood glucose levels in patients with newly diagnosed diabetes or pre-existing diabetes.

RESULTS

This study included 62 confirmed COVID-19 patients with diabetes, including 19 (30.6%) patients with newly diagnosed diabetes and 43 (69.4%) patients with pre-existing diabetes. Patients with newly diagnosed diabetes significantly progressed to a critical condition more frequently during hospitalization than patients with pre-existing diabetes (52.6% vs 20.9%, P = 0.018). In addition, patients with newly diagnosed diabetes had significantly higher average plasma blood glucose levels for the first 3 days after admission than those with pre-existing diabetes.

CONCLUSIONS

Our study suggests that the proportion of COVID-19 patients who are newly diagnosed with diabetes is high, and they have an increased risk of developing severe disease than those with pre-existing diabetes. It might be advisable that at the point of COVID-19 diagnosis, blood glucose and glycated hemoglobin levels be assessed in all patients.

A continuous intravenous insulin infusion protocol to manage high-dose methylprednisolone-induced hyperglycemia in patients with severe COVID-19

Background

Many patients with severe COVID-19 have impaired glucose tolerance, and steroid therapy is a standard treatment. Thus, good glycemic control is important and correlates with better patient outcomes. We began using a continuous intravenous insulin infusion protocol for glycemic control whose infusion rate changes based on the currently measured value and previous value. This study aimed to evaluate this protocol for COVID-19 patients requiring mechanical ventilation.

Methods

This single-center, retrospective, case control study was conducted on all adult patients who required mechanical ventilation for severe COVID-19 pneumonia admitted to our critical care center from April 1, 2020 through June 20, 2021. Blood glucose levels were measured in all patients every 4 h after admission. We started using the insulin infusion protocol from August 1, 2020. Patients before starting the protocol comprised the non-protocol group and those after starting the protocol comprised the protocol group. Blood glucose levels and hypo- or hyperglycemia events were compared between groups. We also surveyed ICU nurses about their experience using the protocol.

Results

During the study period, 173 patients with COVID-19 were admitted. After 15 patients were excluded for several reasons, the study included 158 patients: non-protocol group (n = 14) and protocol group (n = 144). In the initial phase (days 1–2), blood glucose levels of the protocol group were higher compared with the non-protocol group, and as the number of measurements increased, blood glucose levels were gradually brought under control within the target range in the protocol group. Almost no hypoglycemic events (blood glucose < 80 mg/dL) were detected in either group. The rate of hyperglycemia (blood glucose > 300 mg/dL) was about 5–10% in the initial phase in the protocol group and about 10–15% in the early phase (days 3–4) in the non-protocol group. The questionnaire survey revealed that 80% of ICU nurses responded favorably.

Conclusions

This insulin protocol gradually brought the blood glucose level within target levels in severe COVID-19 patients treated with high-dose steroid. Some hyperglycemia events were detected despite patients being under the protocol in the initial phase, and thus, minor modifications of the protocol might be required in the initial phase.