Christine Manga, a diabetes nurse educator, unpacks what steroid-induced diabetes is.
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Can steroids cause diabetes? The short answer is yes. There are a few terms used to describe this: steroid-induced diabetes, glucocorticoid induced hyperglycaemia, and new-onset diabetes after transplant (NODAT).
What are steroids?
Let’s delve into what steroids are, what they are used for, how they work, how they increase glucose levels and more.
The two main types of steroids we are going to discuss are glucocorticoid steroids (GCs) and androgenic/anabolic steroids which are hormones. Our focus will be on glucocorticoid steroids. These hormones are produced naturally in the body.
Testosterone is the naturally occurring androgenic steroid produced mainly in the testes in men and in a very small amount in women in the ovaries. This stimulates the development of male characteristics, such as more bodily hair, especially on the face, chest and underarms, deep voice, larger and stronger muscles. Mood, energy and sexual drive are also partially regulated by testosterone.
Cortisol is produced in the adrenal glands. It’s stimulated in many responses. It regulates our stress response to both physical and psychological stimuli, assists in metabolism, blood pressure and blood glucose regulation, suppresses inflammation (the body’s immune response), and plays a role in the circadian (sleep–wake) cycle as well as many other bodily functions. Testosterone and cortisol are usually produced at optimal levels in the body.
These steroids are also produced synthetically to mimic the effects of those made by the body.
Why are synthetic steroids used and how do they work?
Personal use
Often used by bodybuilders, anabolic steroids, a testosterone-mimicking steroid is usually used by people wanting to bulk up muscle and become stronger in a short period of time. There are also medical reasons to use these.
Medical use
GCs are used to suppress the body’s natural immune response, act as anti-inflammatory and anti-allergic drugs. People using GCs are therefore immunosuppressed. Conditions that would require these medications are usually autoimmune (a disease where the body’s immune system attacks its own healthy cells causing damage to the body). Some examples include: lupus, rheumatoid arthritis, celiac disease, psoriatic eczema, ulcerative colitis, adrenal insufficiency (Addison’s), and multiple sclerosis. These conditions require life-long GCs.
There are other inflammatory conditions that require GCs that are not autoimmune, such as asthma, severe bronchitis, severe allergic reactions. The GCs would be prescribed for acute and not chronic use.
Some people with cancer use them to assist in reducing chemotherapy side effects. People who have undergone an organ transplant will be prescribed life-long GCs to prevent the body from rejecting the new organ by reducing the body’s immune response to the foreign body.
These recipients who do develop diabetes are known as having NODAT.
Steroid preparations
GCs are taken in different preparations: tablets, intravenously, intramuscular injection, inhaled, and applied as a topical (skin) treatment.
Most inhaled and topical applications don’t affect glucose regulation, but long-term use would require monitoring. GCs are divided into three types, short-, intermediate- and long-acting.
How do glucocorticoid steroids affect blood glucose levels?
These steroids are called glucocortico steroids because of their effect on blood glucose levels. GCs make the liver less sensitive to insulin and signals the liver to produce more glucose called gluconeogenesis, even though the pancreas is producing and secreting insulin, albeit less.
Insulin production would normally inhibit gluconeogenesis. Reduced insulin sensitivity means that although the insulin required to transport glucose into muscle and fat cells is there, it’s unable to do the job leaving the glucose in the bloodstream. CGs increase the effects of epinephrine and glucagon which in turn increase glucose levels. These drugs often increase appetite and carbohydrate intake.
Risk factors for developing or worsening diabetes
Individuals who are overweight/obese, have a family history of diabetes, or have a history themselves of elevated glucose levels or prediabetes, and over the age of 50 are at a greater risk of developing steroid-induced diabetes.
Taking high doses for prolonged periods will increase the risk. People who already have diabetes will experience higher than usual glucose levels. People taking GCs are immune suppressed and are therefore also prone to developing other infections.
Other GCs effects on the body
Increased intra-ocular pressure causing glaucoma; this is important to monitor as people with diabetes are already predisposed to developing glaucoma, a leading cause of blindness. Weight gain, skin thinning, muscle weakness, and bone loss can occur. Fat redistribution takes place with long-term GCs use, resulting in fat accumulation around the abdomen and face known as moon face. Mood may be affected too.
How to mitigate the effects of glucocorticoid steroid use
If you already have diabetes, you may need to augment your oral medication with insulin. If already on insulin, dose adjustments will be necessary.
People who did not have diabetes to start will commence on oral medication.
After discontinuation of the GCs, some people will revert to normal blood glucose levels and be able to stop the diabetes medication.
Good food choices, such as smaller portions of carbohydrates and more low GI foods, as well as physical exercise where possible will play a positive role.
Regular monitoring of glucose levels
It’s important to monitor blood glucose levels regularly whilst using GCs. This will assist in early diagnosis of diabetes and timely intervention. People with existing diabetes will need to increase testing frequency. Even after discontinuation of GCs, which must be tapered, three-monthly Hba1c screening is advised.
MEET THE EXPERT
Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.
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