Stacey Divone of New York has lived most of her life with type 1 diabetes (T1D). After recently receiving a round of cortisol steroid shots for back pain, she saw a huge spike in her blood sugars 4 days later, forcing her to hike up her basal insulin rate by 85 percent.
Meanwhile, in Arizona, Tim Hardt remembers being put on the steroid medication prednisone because of a stubborn upper respiratory infection (pre-COVID). Having lived with type 2 diabetes for eight years at that time, he vividly recalls the horrible blood sugar effect that landed him in the emergency room (ER).
After seeing his glucose meter read “Hi” for two days and constantly running to the bathroom, despite taking his normal doses of oral diabetes meds, a phone call to the doctor led his wife to drive Hardt to the hospital. A fingerstick check of 900 mg/dL prompted rounds of emergency insulin shots to get him back to safer levels, and that changed the course of his care forever.
“The ER doctors said they were surprised I was even walking around,” Hardt recalls. “I don’t remember which doctor originally wrote the prescription for prednisone, but they knew I was diabetic and didn’t mention that it could affect my blood sugars like it did. I’ve been on insulin ever since and avoid anything with steroids unless it’s an emergency.”
Neither story is unique. The lion’s share of people with diabetes (PWDs) experience dramatic blood sugar surges after taking steroids, sometimes for just a day or two but often longer. Many find they have to crank up their basal insulin rates, sometimes to three or more times what they normally take.
“One of the things that surprise people is the magnitude of effect [steroids] have on your blood sugars,” says Gary Scheiner, a highly respected diabetes care and education specialist (DCES) in the Philadelphia area. “It doesn’t just raise them a little bit, it’s an enormous increase and can shoot it through the roof.”
Common steroids, such as prednisone and cortisone, help to reduce inflammation and swelling and are used to treat a variety of ailments ranging from arthritis, allergic reactions, respiratory issues and sinus infections, lupus, some cancers, to muscle spasms.
These steroids, known as glucocorticoids, are different from testosterone-based anabolic steroids that some people use to build muscle. The name is derived from “glucose + cortex + steroid” and refers to the fact that they play a role in the regulation of glucose metabolism.
These steroids are found in oral pill or tablet form, a liquid or cream solution, nasal inhaler, injections, or even intravenous therapy (IV), depending on the medical treatment in question.
For PWDs who may be experiencing complications like trigger finger or frozen shoulder, these oral and injected steroid medications are often a common treatment option. But they come with serious side effects to your blood glucose (BG) control.
Per Scheiner, injections tend to have the most significant impact on BGs, while topical creams are less likely to have a glucose effect, though you can find some scattered anecdotes of that happening around the online community.
Among the patient community, glucose-raising action of prednisone and other steroids is often discussed as a side effect, though medical professionals don’t always mention it ahead of time even if they know that a patient has diabetes. A frustration, too, is that not every medication or IV is actually being used for the steroid effect, but it may contain “hidden” steroids that aren’t always disclosed at the time of treatment or medical procedure.
“We see it all the time. Often, people don’t realize there’s cortisone or another type of steroid in [another medication]. Or, healthcare professionals believe there isn’t enough to affect blood sugars, says Dr. David S. Bell, a longtime endocrinologist practicing outside of Birmingham, Alabama.
Some doctors — from podiatrists to rheumatoid arthritis experts — won’t mention the BG effects of a cortisone injection because they believe that it’s localized and doesn’t contain enough of the steroid to get into a person’s system to impact glucose too much. Bell says he heard this from one patient recently who experienced plantar fasciitis in their foot and received a cortisol shot, but the podiatrist specifically said it wouldn’t affect their blood sugar.
“Obviously, anyone with diabetes who’s had these injections knows that isn’t true,” Bell says. “They see a hell of a rise in blood sugars for this, from 5 to 7 days.”
The blood sugar spikes can strike those with diabetes and those without it alike, but it makes co-managing diabetes and conditions requiring steroids tricky, at best. This is sometimes referred to as “steroid-induced diabetes,” a short-term form of type 2 diabetes that disappears soon after the conclusion of steroid use.
Basically, the steroids spike glucose levels by making the liver more resistant to insulin — i.e.,
“Insulin just doesn’t work the way it normally does” when steroids are at play, Scheiner says.
Often, a steroid will cause a huge jump in BG levels that then recovers to normal well before the next dose. These jumps vary depending on the person, the type of steroid, the dose, and the frequency. And the most common finding: These BG spikes are not consistent throughout the day.
Bottom line: Your BG jump may vary.
It takes a lot of insulin to knock down steroid highs. Some people with diabetes may need to take 3, 4, 5, or even 10 times the amount of insulin they’re used to taking in a day. That can be frightening.
There is also the question of using testosterone-boosting anabolic steroids as a way to kickstart muscle development, and how that plays into diabetes.
That topic has grabbed headlines over the years, especially after a 2016 study out of Denmark delved into how anabolic steroids impact insulin resistance and diabetes overall. Led by Dr. Jon Rasmussen at Herlev University Hospital in Copenhagen, a team of researchers looked at the effects of anabolic steroid use on abdominal fat and insulin sensitivity in 100 men, ages 50 or younger, 70 of whom were long-time abusers of these steroids and 30 who were newer to the drug.
Clinical trial verdict: They found no direct proof that anabolic steroids lead to diabetes diagnosis, but they did find that all the study participants, whether long-time anabolic steroids users or not, had markedly low levels of insulin sensitivity (i.e. high insulin resistance).
This implies that while anabolic steroids cause a host of health issues all of their own, they also prompt the same sort of jump in insulin resistance as the other types of steroids — making them an especially poor choice for anyone with diabetes.
Both Scheiner and Bell say they find it surprising how few PWDs actually know about these steroid effects on glucose levels and how many healthcare professionals don’t explain the likely effects to someone with diabetes before giving a steroid injection or prescription.
The advice that PWDs who might be taking steroids should be getting is pretty clear, per this Medical News Today report:
- Check blood glucose levels more often than usual. Experts recommend doing this
four or more timesa day.
- Work with your doctor to increase the dosage of insulin or oral D-medication, depending on blood sugar levels and other health considerations.
- Monitor urine or blood ketones to be sure BG levels aren’t approaching dangerously high.
- See a doctor immediately if BG levels do rise too high while taking steroids, and increased insulin or oral medication doses do not bring the levels down.
- As a person gradually reduces their dosage of steroids, they should also reduce the equivalent dosage of insulin or oral medication until it returns to the original dosage. It is important never to stop taking steroids suddenly, as this may cause severe illness.
- Carry glucose tablets, juice, or candy at all times, in case blood sugar levels drop suddenly from the additional D-medication being taken.
In addition to that textbook advice, Scheiner adds some practical tips:
- Wait at least 4 to 6 hours to adjust any insulin doses, since the steroid effect often isn’t immediate.
- Start with a basal rate increase of 50 percent, whether that be with a temporary basal rate program on your insulin pump or a larger dose of long-acting insulin by pen or vial.
- Next, take a “play it by ear” approach based on the individual BG response.
- The biggest glucose spikes typically appear and peak on days 2 or 3, though sometimes that can happen on day 4. These are often the days requiring the biggest basal rate increases for most patients.
- Most insulin pumps won’t allow a temporary basal rate of more than 200 or 250 percent, so that may require an extra basal rate to be programmed into the device.
- A continuous glucose monitor (CGM) can be a very beneficial tool to use during these times to keep track of glucose levels that may fluctuate significantly because of the steroids. Yet, turning off CGM alerts can also be helpful to avoid alert fatigue.
Bell says dealing with these steroid-related BG rises usually means increasing short-acting insulin and/or insulin pump basal rates.
“If I can get ahead of it, I can make sure they’re aware of it,” he says. “My advice to most people, in general, is know what’s in the medications you’re getting.”
The obvious caveat to all of this is that (as always), individual diabetes experiences may vary.
When DiabetesMine reached out to the diabetes online community (DOC) on this topic, dozens replied saying they’d experienced huge jumps in blood sugar after using various types of steroids.
Laura Higgins of Utah, who’s lived with T1D for almost two decades since age 13, says she’s seen big BG spikes after being on steroids several times through the years. But she knew the risks and worked with her diabetes education and care specialist to best manage those fluctuations.
Her partner had a different story, however. He was diagnosed with type 2 diabetes a couple of years before they started dating, and earlier this year an urgent care doctor prescribed steroids for bronchitis, without even inquiring or looking at his chart, and not explaining the blood-sugar risks and potential for diabetes ketoacidosis (DKA).
“By this time I had coached him into how to manage his diabetes and he was testing with all these crazy numbers over 400 mg/dL,” she says. She noted that with her backup Novolog insulin pen she had taught him to use, her husband was dosing 30+ units to bring his numbers down to more manageable levels.
“He finished the steroids and I got him in with the primary care doctor that my manages my type 1 because I was so appalled at the negligence,” she tells DiabetesMine.
In Washington, Diane Sperson, who was diagnosed with T1D in her 30s in 1989, says she had very high blood sugars that were “very difficult to bring down” the entire time taking prednisone and for a time after. She didn’t eat very much at all to help keep her blood sugars in check before eventually seeing her provider and deciding to discontinue the steroid. “It was fairly early in my diabetes journey in the 90s, so I didn’t have the skills and tools at my disposal that I do now. But I have always opted out since then.”
Others echoing similar experiences preferred to have their names withheld:
“I had to get some steroid injections while pregnant to boost my daughter’s lung development because there were concerns of premature birth,” one woman wrote. “For those 2 or 3 days, my levels soared and no matter how much insulin I took they didn’t budge.”
One T1D commented: “I received a cortisone injection in the arch of my foot several years ago and my blood sugar spiked very high for days after the injection. My usual insulin for correction was not much help.”
Plus this one: “Very, very large spikes in blood sugar for at least a week or two after. Endo said to only take if in a life-or-death situation.”
Others shared their frustrations with out-of-control high blood sugars even after boosting insulin doses for days, up to 150 percent more for long-acting insulin, and 200 percent more for short-acting insulin doses.
Many people using CGM said that using this tech to keep tabs on their BG was even more of a lifesaver than usual while struggling with the effects of steroid use. Some noted that they took Scheiner’s advice and turned off the High alerts just to maintain their own mental health and not go crazy with constant alarms while spiking so often.
If you have diabetes, be aware that steroid use will spike your blood sugar — be very aware, in fact, because this can be dangerous.
Depending on the meds you’re taking, there can be many nuances to combating this effect, so it’s always critical to talk with your healthcare professionals for any issues related to steroid use and diabetes management.