How to manage steroid diabetes in the patient with cancer.

perglycemic nonketotic hyperosmolar coma may even ensue. Increased steroid levels are not the only factor promoting diabetes in cancer patients; infection, inactivity, emotional stress, intravenous glucose, and high carbohydrate diets also increase the tendency toward hyperglycemia. Multiple reviews have emphasized the importance of intensive insulin therapy in hospitalized patients,2–5 and several studies reinforce the importance of tight glucose control in this patient population. Furnary et al1,6,7 showed that aggressive control of postoperative blood glucose levels in diabetic patients who had undergone a coronary artery bypass graft reduced sternal wound infections and also improved morbidity and mortality. The Diabetes Mellitus, Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study8 showed that, compared with conventional therapy, 48 hours of tight glucose control in patients with acute myocardial infarction reduced mortality. The Van den Berghe study9 may be relevant to steroid-induced hyperglycemic patients, since the study population consisted largely of patients in the intensive care unit (ICU) not known to be diabetic who developed hyperglycemia in the hospital. This response may have been related to the infused glucose and the stress-induced endogenous steroid production. Patients who had a glucose reading above 110 mg/dL were randomized to receive intensive insulin therapy or conventional therapy. Patients in the intensive insulin group received insulin infusions set to reduce their glucose level to 80–110 mg/dL, whereas those in the conventional therapy group received insulin treatment only if the glucose level went above 215 mg/dL and maintenance of glucose at a level between 180 and 200 mg/dL. The final glucose averages of the intensive and conventional groups were 103 mg/dL and 153 mg/dL, respectively. The benefits of tight glucose control in the intensive insulin group included a reduction in overall mortality, particularly in patients who remained in the ICU > 5 days, and a reduced risk of sepsis, transfusions, renal failure, and ICU Correspondence to: David S. Oyer, MD, 211 E. Chicago Avenue, Suite 1050, Chicago, IL 60611; telephone: (312) 9446677; fax: (312) 944-3346; e-mail: [email protected] Dr. Oyer is Assistant Professor of Clinical Medicine, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Mr. Shah is a medical student, the University of Texas Southwestern Medical School, Dallas. Ms. Bettenhausen is a Clinical Nurse Specialist and Certified Diabetes Educator, Associates in Internal Medicine, Ltd., Chicago, Illinois. How to Manage Steroid Diabetes in the Patient With Cancer