College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia
Eur J Endocrinol. 2018 Oct 1;179(4):R207-R218. doi: 10.1530/EJE-18-0315.
Glucocorticoids are frequently prescribed to patients with a wide range of inflammatory and autoimmune diseases. The semi-synthetic glucocorticoid prednisolone is most commonly prescribed and in two main patterns. Prednisolone is prescribed short term at medium-high doses to treat an acute inflammatory illness or long term at lower doses to attenuate chronic inflammatory disease progression. In hospitalized patients with acute prednisolone-induced hyperglycaemia, there is a distinct circadian pattern of glucose elevation, which occurs predominantly in the afternoon and evening. As a morning dose of isophane insulin has a pharmacokinetic pattern that matches this pattern of glucose elevation, treatment comprising a basal dose of morning isophane insulin in combination with short-acting insulin boluses is generally recommended. However, evidence is lacking that isophane-based basal bolus insulin is more efficacious than other insulin regimens. In outpatients, low-dose prednisolone causes a small increase in post glucose-load glucose concentration but no change in overall glycaemic control as measured by glycosylated haemoglobin. If treatment is indicated, metformin has been shown to be effective and may attenuate other adverse effects of long-term prednisolone therapy. Further studies are necessary in order to identify factors underlying the variability in response to insulin therapy and clinical benefits of treatment in hospitalized patients with prednisolone-induced hyperglycaemia. In outpatients prescribed low-dose prednisolone, the cardiovascular risk associated with postprandial hyperglycaemia and efficacy of hypoglycaemic therapies should be evaluated in future randomized clinical trials.
糖皮质激素常用于治疗各种炎症性和自身免疫性疾病的患者。半合成糖皮质激素泼尼松龙是最常被开处的药物，主要有两种应用模式。短期应用中高剂量泼尼松龙治疗急性炎症性疾病，或长期应用低剂量泼尼松龙减轻慢性炎症性疾病进展。在因急性泼尼松龙诱导性高血糖住院的患者中，存在明显的葡萄糖升高昼夜节律模式，主要发生在下午和晚上。由于中效胰岛素的药代动力学模式与葡萄糖升高的模式相匹配，因此通常建议使用早晨给予中效胰岛素的基础剂量，并联合使用短效胰岛素推注。然而，缺乏证据表明基于异羟戊酸的基础-冲击胰岛素方案比其他胰岛素方案更有效。在门诊患者中，小剂量泼尼松龙会导致葡萄糖负荷后血糖浓度略有升高，但糖化血红蛋白测量的整体血糖控制没有变化。如果需要治疗，二甲双胍已被证明有效，并且可能减轻长期泼尼松龙治疗的其他不良反应。为了确定导致对胰岛素治疗反应性的变异性和治疗住院患者泼尼松龙诱导性高血糖的临床获益的因素，还需要进一步的研究。在接受低剂量泼尼松龙治疗的门诊患者中，应该在未来的随机临床试验中评估餐后高血糖相关的心血管风险以及降血糖治疗的疗效。
