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  • Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review

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Diabetes and endocrinology
Research
Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review
  1. Milos Tatalovic1,
  2. Roger Lehmann2,
  3. Marcus Cheetham1,3,
  4. Albina Nowak2,
  5. Edouard Battegay1,3,
  6. Silvana K Rampini1
  1. 1 Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
  2. 2 Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
  3. 3 Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland
  1. Correspondence to Dr Silvana K Rampini; silvana.rampini{at}usz.ch

Abstract

Objectives What is the most effective pharmacological intervention for glycaemic control in known type 2 diabetes mellitus (DM) without prior insulin treatment and newly started on systemic glucocorticoid therapy?

Design We conducted a systematic literature review.

Data sources We searched MEDLINE, Embase and Cochrane Library databases and Google for articles from 2002 to July 2018.

Eligibility criteria We combined search terms relating to DM (patients, >16 years of age), systemic glucocorticoids, glycaemic control, randomised controlled trials (RCTs) and observational studies.

Data extraction and synthesis We screened and evaluated articles, extracted data and assessed risk of bias and quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation guidelines.

Results Eight of 2365 articles met full eligibility criteria. Basal-bolus insulin (BBI) strategy for patients under systemic glucocorticoid therapy was comparatively effective but provided insufficient glucose control, depending on time of day. BBI strategy with long-acting insulin and neutral protamin Hagedorn as basal insulin provided similar overall glycaemic control. Addition of various insulin strategies to standard BBI delivered mixed results. Intermediate-acting insulin (IMI) as additional insulin conferred no clear benefits, and glycaemic control with sliding scale insulin was inferior to BBI or IMI. No studies addressed whether anticipatory or compensatory insulin adjustments are better for glycaemic control.

Conclusion The lack of suitably designed RCTs and observational studies, heterogeneity of interventions, target glucose levels and glucose monitoring, poor control of DM subgroups and low to moderate quality of evidence render identification of optimal pharmacological interventions for glycaemic control and insulin management difficult. Even findings on the widely recommended BBI regimen as intensive insulin therapy for patients with DM on glucocorticoids are inconclusive. High-quality evidence from studies with well-defined DM phenotypes, settings and treatment approaches is needed to determine optimal pharmacological intervention for glycaemic control.

PROSPERO registration number CRD42015024739.

  • type 2 diabetes
  • hyperglycaemia
  • glucocorticoid therapy
  • hypoglycaemic agent
  • NPH insulin
  • BBI

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2019-028914

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    Footnotes

    • Contributors MT drafted the study; contributed to the development of the selection criteria and data extraction criteria; developed the search strategy; elaborated the study selection, data extraction and data synthesis; wrote the manuscript; provided feedback and approved the final manuscript. RL provided expertise on diabetes mellitus, read the manuscript, provided feedback and approved the final manuscript. MC contributed to the writing of the manuscript. AN read, provided feedback and approved the final manuscript. EB drafted the study, contributed to the development of the selection criteria and data extraction criteria, read the manuscript, provided feedback and approved the final manuscript. SKR is the guarantor; drafted the study; contributed to the development of the selection criteria and data extraction criteria; did the study selection, data extraction and data synthesis; wrote the manuscript; provided feedback and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data relevant to the study are included in the article or uploaded as supplementary information.

    • Patient consent for publication Not required.