Alternate day corticosteroid causes alternate day hyperglycaemia

Advantages of an alternate-day glucocorticoid treatment strategy for the treatment of IgG4-related disease: A preliminary retrospective cohort study

Alternate-day glucocorticoid (GC) therapy is a treatment option that can reduce GC-associated adverse events. We investigated the safety and efficacy of alternate-day GC therapy in patients with immunoglobulin G4-related disease (IgG4-RD). Medical records of patients with IgG4-RD who were followed for at least one year at St. Luke's International Hospital, Tokyo, Japan, from 2004 to 2020 were reviewed. Patients who fulfilled comprehensive IgG4-RD diagnostic criteria were divided into alternate-day or daily GC treatment groups based on their treatment protocol. The effect of alternate-day GC therapy on glucocorticoid toxicity index (GTI) score was evaluated using multilinear analysis with adjustments for cumulative GC doses until each assessment point and propensity scores (PS) for alternate-day GC therapy. Kaplan-Meier curves and Cox proportional hazard models were used to assess the efficacy of alternate-day GC therapy for disease control. Among the 67 patients with IgG4-RD, patients with alternate-day (n = 13) and daily (n = 31) GC treatments were analyzed after excluding 23 ineligible patients. The median (interquartile range) age was 64 (60-70) years, 29 (65.9%) were male patients, 26 (59.1%) patients had positive biopsy results, and the median follow-up period was 1643 days. Significantly more patients with alternate-day GC treatment used concomitant immunosuppressants (11 [84.6%] vs 11 [35.5%]; P = .007). The alternate-day strategy significantly lowered the GTI score after adjusting for cumulative GC dose until the assessment and PS (adjusted coefficient: -29.5 [-54.3, -4.8], P = .021 at 12 months; -20.0 [-39.8, -0.1], P = .049 at 24 months). Serious infections were numerically less frequent in the alternate-day group (incidence ratio [95% confidence interval [CI]: 0.45 [0.05, 3.63], P = .45). Most patients (92.3%) in the alternate-day GC treatment group and all patients in the daily GC treatment group showed treatment responses in the remission induction therapy. The PS-adjusted hazard ratio of alternate-day GC treatment for disease flares was not significant (1.55 [0.53, 4.51]; P = .43). The alternate-day treatment strategy significantly reduced GC-related adverse events regardless of the cumulative GC dose. Alternate-day GC treatment is a feasible option for patients with IgG4-RD, without a significant increase in disease flares particularly when combined with immunosuppressants.

Prevalence, severity, and nature of risk factors associated with drug-drug interactions in geriatric patients receiving cancer chemotherapy: A prospective study in a tertiary care teaching hospital

INTRODUCTION

Polypharmacy increases hazard of drug-drug interactions(DDIs), hospitalization, treatment toxicity, and mortality in elderly individuals with cancer. The present study explores and analyzes prevalence and severity of DDIs in geriatric cancer patients subjected to anticancer chemotherapy, their mechanisms, stratification of severity, and correlation between DDI risk and number of medications taken.

METHODS

This was a cross-sectional study conducted between January-July 2019 at the Medical Oncology/Hematology and Radiation-Oncology Departments, All India Institute of Medical Sciences(AIIMS) Rishikesh. The study included a convenience sampling of 126 geriatric cancer patients.

RESULTS

126 patients were enrolled in present study. DDIs were identified in 97.6% of elderly cancer patients, and 88.9% had at least one DDI with antineoplastic medications. Highest number of DDIs involving antineoplastic medications in any given patient was 12. DDIs involving medications used for treatment of non-cancerous diseases were observed in 83.3% of patients; highest number of interactions identified in any given patient was 15. Out of 473 interactions, 237(50.1%) DDIs were attributable to pharmacodynamic mechanisms of action. 126(27%) of DDIs involved pharmacokinetic mechanisms and 110(23.6%) involved unknown mechanisms. In this present study, total number of DDIs could be positively correlated with total number of medications and number of health problems.

CONCLUSIONS

Geriatric cancer patients are at high risk of DDIs ascribable to polypharmacy. Physicians may utilize online DDI checking softwares to alert themselves, characterize potential DDIs, and modify medications judiciously. An integrative and algorithmic approach with inclusion of geriatricians, oncologists, cardiologists, general practitioners, and clinical pharmacologists/ pharmacists is imperative to optimize drug therapy.

[Corticosteroids and diabetes mellitus]

During corticosteroid prescriptions, diabetes mellitus may be completely deregulated or may be revealed as such. Predisposition to diabetes mellitus could be because of latent β Langerhans cell deregulation or because enhancement of tissue sensitivity by glucocorticosteroids. However, epidemiologic data concerning predisposing factors and frequency of cortico-induced diabetes are not well known. Detection, treatment and prevention are the same as for type II diabetes. Glycemia should be monitored throughout long-term treatments.

Revisiting the Toxicity of Low-Dose Glucocorticoids: Risks and Fears

We have recently participated in a careful literature search and critical evaluation of glucocorticoids, and we have revised the side-effects data of four recent controlled trials of low-dose glucocorticoids (GCs) in rheumatoid arthritis. The toxicity profile stands out as remarkably more benign than expected from most textbook recommendations. Data regarding low-dose therapy are scarce and of low quality, as no controlled trials have been designed to specifically address toxicity. Common fears of GC toxicity seem to originate from an excessive weight on anecdotal data and observations with high doses, as in organ transplantation. There is now evidence that mechanisms of action of GCs vary considerably according to the dose, thus allowing the possibility of a different toxicity profile. Data from recent controlled trials are quite reassuring, overall. Certainly, risks and benefits of GCs need to be carefully weighed in every patient. But we need to make a clear distinction between established risks and unchecked fears while trying to get the best result for our patient. Clearly, there is a need for studies that are appropriately designed to address the toxicity of GCs and to avoid the risk of "throwing out the baby with the bath water."

Safety of low dose glucocorticoid treatment in rheumatoid arthritis: published evidence and prospective trial data

Adverse effects of glucocorticoids have been abundantly reported. Published reports on low dose glucocorticoid treatment show that few of the commonly held beliefs about their incidence, prevalence, and impact are supported by clear scientific evidence. Safety data from recent randomised controlled clinical trials of low dose glucocorticoid treatment in RA suggest that adverse effects associated with this drug are modest, and often not statistically different from those of placebo.

Effects of glucocorticosteroids on the skin and eye

The dermatologic anachronistic adage, "If wet--dry it, if dry--wet it!" has bee perhaps justifiably replaced by "Call the dermatologist to prescribe a steroid!" To say this without knowledge of the contents of this article and more importantly, to accept such cliches, is a disservice to the patient and a litigious liability to the prescriber. Recognizing the risk/benefit ratio of the most commonly used anti-inflammatory agents is essential. All therapies are most effective when used for their specific diagnosis. This article attempts to provide an update on the geometrically progressing knowledge regarding the uses and misuses of GCSs for the eye and skin.

Perioperative management of type 1 diabetes mellitus

Clearly, perioperative management of diabetic patients requires thorough preoperative evaluation and planning whenever possible. A firm understanding of the pathophysiology of type 1 diabetes mellitus, the metabolic stress response, and the interactions between various forms of insulin and other variables such as supplemental nutrition and glucocorticoids can greatly assist in achieving a positive outcome. Consultation with an endocrinologist, internist, or other primary care provider comfortable with managing type 1 diabetes patients is strongly recommended to assist in the details of in-patient care and overseeing of proper ancillary support. It may also be helpful to allow the patient to function as an active decision-maker in the coordination of care, especially because a large percentage of type 1 diabetes patients (particularly those who are on insulin pumps) are well-educated about their disease process and their own physiologic idiosyncrasies. This knowledge can save valuable time and effort toward achieving the ultimate united goal of avoiding perioperative morbidity and mortality by maximizing glycemic control.

Drug selection and the management of corticosteroid-related diabetes mellitus

Glucocorticoid use is associated with the risk of hyperglycemia in patients without known diabetes mellitus and worsened glycemic control in diabetic patients. The effects are greater in the fed than fasting state. Management includes use of diet and exercise (as appropriate for the individual) in all patients. Mild hyperglycemia can often be managed with oral agents, especially those with rapid onset of action. Marked hyperglycemia, especially in diabetic patients or patients with liver or renal disease, requires insulin. Adjustments in insulin can be done both in anticipation of the glucocorticoid effect and based on home glucose monitoring. The effects of glucocorticoids on hyperglycemia usually remit within 48 hours of discontinuation of oral administration.

Acute glucosuria after continuous glucocorticoid loading in the rat in vivo

We investigated the effects of the continuous infusion of various steroids in rats on renal tubular reabsorption of glucose in vivo to elucidate the pathogenesis of steroid-induced glucosuria. Urinary glucose excretion increased 60 min after administration of dexamethasone (2.38 mM). By 120 min, urinary excretion of glucose was three times higher in the dexamethasone group than in the control group (24.1 +/- 4.6 versus 72.4 +/- 16.7 micromol); the plasma level of glucose did not increase. Dexamethasone had no effect on the resorption of 1,5-anhydro-D-glucitol, which is a glucose-resembling polyol that is actively absorbed by the renal tubules as glucose. Neither estradiol nor progesterone increased urinary excretion of glucose. These findings suggest that continuous administration of a high-dose glucocorticoid selectively influences the glucose reabsorption system in the kidney.

Increased hepatic glucose production response to glucagon in trained subjects

This study was designed to characterize the impact of endurance training on the hepatic response to glucagon. We measured the effect of glucagon on hepatic glucose production (HGP) in resting trained (n = 8) and untrained (n = 8) healthy male subjects (maximal rate of O2 consumption: 65.9 +/- 1.6 vs. 46.8 +/- 0.6 ml O2.kg-1.min-1, respectively, P < 0.001). Endogenous insulin and glucagon were suppressed by somatostatin (somatotropin release-inhibiting hormone) infusion (450 micrograms/h) over 4 h. Insulin (0.15 mU.kg-1.min-1) was infused throughout the study, and glucagon (1.5 ng.kg-1.min-1) was infused over the last 2 h. During the latter period, plasma glucagon and insulin remained constant at 138.2 +/- 3.1 vs. 145.3 +/- 2.1 ng/l and at 95.5 +/- 4.5 vs. 96.2 +/- 1.9 pmol/l in trained and untrained subjects, respectively. Plasma glucose increased and peaked at 11.4 +/- 1.1 mmol/l in trained subjects and at 8.9 +/- 0.8 mmol/l in untrained subjects (P < 0.001). During glucagon stimulation, the mean increase in HGP area under the curve was 15.8 +/- 2.8 mol.kg-1.min-1 in trained subjects compared with 7.4 +/- 1.6 mol.kg-1.min-1 in untrained subjects (P < 0.01) over the first hour and declined to 6.8 +/- 2.8 and 4.9 +/- 1.4 mol.kg-1.min-1 during the second hour. In conclusion, these observations indicate that endurance training is associated with an increase in HGP in response to physiological levels of glucagon, thus suggesting an increase in hepatic glucagon sensitivity.

Diabetes management in special situations

Clinicians are frequently required to manage situations for which few data are available in the literature. Medical therapies for these situations are frequently based on graduate and postgraduate training, community standards, and personal experience. For individuals with diabetes, this would include perioperative diabetes management, the management of diabetes while discontinuing an insulin infusion, and the management of diabetes during treatment with glucocorticoids and TPN. Clinicians may disagree with some of the recommendations for these four situations, and implementation of these suggestions may not be possible at all hospitals. The therapies described herein are based on the pathophysiology of the respective situation and the pharmacokinetic and pharmacodynamic properties of available medications, particularly insulin. The introduction of new insulin analogues and agents to treat insulin resistance may improve our ability to treat diabetes in special situations. Future investigations should focus on how to best use these tools during critical times.

Effect of glucocorticoid replacement therapy on glucose tolerance and intermediary metabolites in hypopituitary adults

BACKGROUND AND OBJECTIVES

Excess impaired glucose tolerance and diabetes mellitus have been reported in hypopituitary adults on conventional replacement therapy including glucocorticoids. We investigated the effect of the glucocorticoid component on glucose tolerance and intermediary metabolites in hypopituitary adults.

DESIGN

A 3-hour 75-g oral glucose tolerance test (OGTT) was performed on two study days, at least one week apart. On one study day, the glucocorticoid replacement morning dose was taken 60 minutes before the OGTT, and on the other it was left until after the OGTT. All other pituitary replacement therapies were kept unchanged on the two study days.

PATIENTS

Eight hypopituitary adults (3 males and 5 females; aged 46-76 years) on conventional replacement therapy were studied. Their duration of hypopituitarism was mean (range) 15 (5-31) years. Their mean body mass index (BMI) was 28.4 (24.1-35.1) kg/m2. Their total daily cortisol dose was 26 (15-30) mg.

MEASUREMENTS

Plasma glucose, insulin, non-esterified fatty acids (NEFA), glycerol and 3-hydroxybutyrate were measured at 30-minute intervals and plasma cortisol levels were measured hourly.

RESULTS

Fasting glucose and insulin concentrations were similar on the glucocorticoid day (GD) and the non-glucocorticoid day (NGD) (glucose (mean +/- SD) 4.9 +/- 0.9 vs 4.4 +/- 0.5 mmol/l; insulin (median (range)) 5 (1-17) vs 2 (1-15) mU/l, respectively). Post-glucose glycaemia was higher on the GD than on the NGD with a significantly higher glucose area under the curve (AUC) (45.0 +/- 8.2 vs 38.9 +/- 11.7 mmol/l h, P < 0.05). Post-glucose insulinaemia was also higher on the GD than on the NGD with significantly higher insulin AUC (270 (47-909) vs 207 (46-687) mU/l h, P < 0.02). Impaired glucose tolerance was found in three patients on the GD, one of whom continued to have impaired glucose tolerance on the NGD. The areas under the curves of NEFA, glycerol and 3-hydroxybutyrate were not significantly different on the two days. On the NGD, plasma cortisol levels were undetectable (< 50 nmol/l) in all patients and on the GD the median (range) peak was 500 (330-740) nmol/l dropping to 125 (60-330) nmol/l at 180 minutes. The difference in glucose AUC between the two days correlated with the maximal plasma cortisol levels (Spearman's p = 0.83, P < 0.01).

CONCLUSIONS

Glucocorticoid replacement therapy taken pre-prandially in hypopituitary adults induces mild elevations in circulating glucose and insulin levels even with acceptable plasma cortisol concentrations. Optimal regimens for glucocorticoid replacement require more study.

Drug-induced diabetes

The only drugs which commonly cause diabetes during therapeutic use are the anti-hypertensive vasodilator diazoxide, and corticosteroids in high doses such as those used to palliate intracranial tumours. Thiazide diuretics have in the past been used in higher doses than necessary to treat hypertension, and the lower doses now used probably carry only a slight risk of inducing diabetes. The risk from beta-blockers is also quite small, but there is some evidence that thiazides combined with beta-blockers may be more likely to cause diabetes than either drug alone. The combination is probably best avoided in patients with a family history of non-insulin-dependent diabetes. The effect of the low-oestrogen combined oral contraceptive pill seems to be slight, and it presents a risk only to women who have had gestational diabetes. Bodybuilders who take enormous doses of anabolic-androgens can develop impaired glucose tolerance. Several drugs, including theophylline, aspirin, isoniazid and nalidixic acid can cause transient hyperglycaemia in overdosage, but only streptozotocin, alloxan and the rodenticide Vacor are likely to cause permanent diabetes.