Hyperglycemia related to high-dose glucocorticoid use in noncritically ill patients

BACKGROUND

Glucocorticoids commonly cause drug-induced diabetes. This association is well recognized but available evidence does not answer clinically relevant issues in subjects without diabetes.

METHODS

Thirty-five individuals without diabetes with a recent diagnosis of acute lymphoblastic leukemia or non-Hodgkin's lymphoma on high-dose glucocorticoid therapy were studied. Close systematic monitoring of fasting and postprandial glycemia and fasting insulin determinations, HOMA-insulin resistance and HOMA β-cell function were performed. The primary objective was to define the incidence of secondary diabetes in patients treated with high-dose glucocorticoids. Secondary objectives were to specify the intensity, the moment it appears and the evolution of hyperglycemia, in addition to the risk factors, mechanisms and impact of continuous and cyclical glucocorticoids on the development of hyperglycemia.

RESULTS

Mean age of patients was 38.4 ± 18.7 years. The incidence of diabetes was 40.6% and was found after the first week; half the time it occurred between the second and fourth. Two-thirds spontaneously normalized by eight weeks. Continuous glucocorticoid administration had a higher incidence of fasting hyperglycemia (P = 0.003). Mean peak insulin levels were significantly higher in cases of diabetes.

CONCLUSIONS

High-dose prednisone for 2 to 3 months produced an elevated incidence of diabetes, usually with mild hyperglycemia occurring between the second and fourth week, normalizing spontaneously in all cases. Hyperglycemia was more frequent with continuous doses and occurred in cases with increased insulin resistance. The clinical and therapeutic characteristics of our participants, who were otherwise healthy, could represent the clinical setting of many patients with illness from other medical areas that might require high doses of GC for six to twelve weeks.

Drugs and hyperglycemia: A practical guide

Drug-induced diabetes is one of the factors contributing to the increasing incidence of diabetes worldwide. This review considers the frequency, pathogenesis and treatment of drug-induced diabetes. Drugs that induce diabetes include hormonal therapy, especially glucocorticoids and androgen blockers, cardiovascular drugs, especially statins, beta-blockers and diuretics, antipsychotics, especially clozapine, olanzapine and quetiapine, antiretrovirals (protease inhibitors and non-reverse transcriptase inhibitors - NRTIs) and other drugs (mechanistic target of rapamycin inhibitors -mTORs, post organ transplantation drugs, tyrosine kinase inhibitors and interferon-alpha). Abnormalities of the distal gluco-regulatory pathways of hyperglycemia involve decreased insulin secretion and frequent insulin resistance, whereas the proximal defects are unknown, thus limiting targeted treatment. Drug-induced diabetes is potentially reversible and the risk is underestimated. There is little information on its long-term effects on microvascular complications as clinical trials have not been long enough and neither have they focused on these factors. Overall management includes awareness of a drug's diabetogenic potential, underlying diabetes risk, benefits and risks of continuing vs discontinuing the drug, plus a consideration of drug duration and dose. While diabetes and its severity can be identified and controlled, the likelihood of future diabetes complications frequently cannot. This, balanced against the predicted benefit of the drug, results in clinical uncertainty. Empirical approaches to drug-related hyperglycemia include decreasing the dose or selecting an alternative treatment, if possible. In the absence of drug-specific evidence, treatment of drug-induced hyperglycemia and diabetes is similar to comprehensive standard diabetes care, including lifestyle modifications, oral/injectable antidiabetic agents and insulin. Important clinical considerations include surveillance of glucose before and during treatment and, in some cases, institution of diabetes preventive measures like lifestyle modification and early treatment. Future research is needed to elucidate pathophysiology and optimal targeted treatment for drug-induced diabetes and its long-term complications.

When therapeutic drugs lead to diabetes

Drug-induced diabetes mellitus is a growing problem in clinical practice. New, potent medications contribute to this problem in a population already at high risk of developing glucose disturbances because of poor lifestyle habits and high prevalence of being overweight/obese. The present review focuses on four important pharmacological classes: glucocorticoids; antipsychotics, especially second generation; antiretroviral therapies, which revolutionised the management of individuals with HIV; and immune checkpoint inhibitors, recently used for the immunotherapy of cancer. For each class, the prevalence of drug-induced diabetes will be evaluated, the most common clinical presentations will be described, the underlying mechanisms leading to hyperglycaemia will be briefly analysed, and some recommendations for appropriate monitoring and management will be proposed.

Drug-induced hyperglycaemia and diabetes: pharmacogenomics perspectives

Drug-induced diabetes is widely reported in clinical conditions, and it is becoming a global issue because of its potential to increase the risk of severe cardiovascular complications. However, which drug mechanisms exert their diabetogenic effects and why the effects present significant inter-individual differences remain largely unknown. Pharmacogenomics, which is the study of how genomic variation influences drug responses, provides an explanation for individual differences in drug-induced diabetes. We highlight that pharmacogenomics can be involved in regulating the expression of genes in signaling pathways related to the pharmacokinetics or pharmacodynamics of drugs or the pathogenesis of diabetes, contributing to the differences in drug-induced glucose impairment. The pharmacogenomics studies of the major diabetogenic drugs are reviewed, including calcineurin inhibitors, antipsychotics, hormones, and antihypertensive drugs. We intend to elucidate the genetic basis of drug-induced diabetes and pave the way for the precise use of these drugs in the clinic.

Drug-induced hyperglycemia and diabetes

BACKGROUND

Drug-induced hyperglycemia and diabetes have negative and potentially serious health consequences but can often be unnoticed.

METHODS

We reviewed the literature searching Medline database for articles addressing drug-induced hyperglycemia and diabetes up to January 31, 2023. We also selected drugs that could induce hyperglycemia or diabetes according official data from drug information databases Thériaque and Micromedex. For each selected drug or pharmacotherapeutic class, the mechanisms of action potentially involved were investigated. For drugs considered to be at risk of hyperglycemia or diabetes, disproportionality analyses were performed using data from the international pharmacovigilance database VigiBase. In order to detect new pharmacovigilance signals, additional disproportionality analyses were carried out for drug classes with more than 100 cases reported in VigiBase, but not found in the literature or official documents.

RESULTS

The main drug classes found to cause hyperglycemia are glucocorticoids, HMG-coA reductase inhibitors, thiazide diuretics, beta-blockers, antipsychotics, fluoroquinolones, antiretrovirals, antineoplastic agents and immunosuppressants. The main mechanisms involved are alterations in insulin secretion and sensitivity, direct cytotoxic effects on pancreatic cells and increases in glucose production. Pharmacovigilance signal were found for a majority of drugs or pharmacological classes identified as being at risk of diabetes or hyperglycemia. We identified new pharmacovigilance signals with drugs not known to be at risk according to the literature or official data: phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, sodium oxybate, biphosphonates including alendronic acid, digoxin, sartans, linosipril, diltiazem, verapamil, and darbepoetin alpha. Further studies will be needed to confirm these signals.

CONCLUSIONS

The risks of induced hyperglycemia vary from one drug to another, and the underlying mechanisms are multiple and potentially complex. Clinicians need to be vigilant when using at-risk drugs in order to detect and manage these adverse drug reactions. However, it is to emphasize that the benefits of appropriately prescribed treatments most often outweigh their metabolic risks.

Sesamol combats diabetogenic effects of atorvastatin through GLUT-4 expression and improved pancreatic viability

Statin-associated diabetes (SAD) is an issue that has come to light after a series of recent clinical trials that has led to the issue of a black box warning for statins by the US FDA. However, the benefit of statin outweighs its risk. Nevertheless, experiments have been conducted to identify the mechanism by which statins aggravate the risk of diabetes only in a select population who bear the risk factors of obesity, sedentary lifestyle, hypertension, and other associated risk factors of lifestyle disorders. In this study, the possibility of utilization of a phyto-molecule, sesamol, for its ability to combat statin-associated diabetes using atorvastatin as the agent of choice has been explored. MMP assay and western blot was conducted to investigate the effects of atorvastatin on apoptotic cascade with sesamol as a protective agent was conducted in MIN-6 cells. Effect of the combination was tested in L6 cells with 2-NBDG uptake assay and as well as western blot for GLUT-4. A diet-induced hypercholesterolemia model was developed in an in vivo model animals and treated with atorvastatin and sesamol with histopathological analysis being carried out to evaluate the apoptotic markers and GLUT-4 presence. It was found that sesamol can combat pancreatic beta cell apoptosis via the internal apoptotic pathway activated by atorvastatin. With regards to muscle cells, sesamol could improve the GLUT-4 vesical production, but not improve glucose uptake which is inhibited by atorvastatin. These findings are further confirmed by animal studies. These findings indicate that sesamol can serve as a prototype molecule for further development and investigation of similar compounds to tackle SAD.

Medication-Induced Hyperglycemia and Diabetes Mellitus: A Review of Current Literature and Practical Management Strategies

With the increasing global incidence of diabetes mellitus, physicians may encounter more patients with acute and chronic complications of medication-induced hyperglycemia and diabetes. Moreover, medication-induced diabetes may be an important contributing factor to the high rates of diabetes, and recognizing its impact and risk is a critical step in curtailing its effect on the global population. It has long been recognized that multiple classes of medications are associated with hyperglycemia through various mechanisms, and the ability to foresee this and implement adequate management strategies are important. Moreover, different antihyperglycemic medications are better suited to combat the hyperglycemia encountered with different classes of medications, so it is critical that physicians can recognize which agents should be used, and which medications to avoid in certain types of medication-induced hyperglycemia. In this review, we will discuss the evidence behind the main classes of medications that cause hyperglycemia, their mechanism of action, specific agents that are associated with worsened glycemic control, and, most importantly, management strategies that are tailored to each specific class.