BJD

Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK

Exogenous glucocorticoids are commonly prescribed medication used across a large variety of medical and surgical specialities for their excellent anti-inflammatory properties. However, the advantages to using glucocorticoids must be balanced against their many well described adverse effects.¹In particular, excessive glucocorticoid use contributes to whole-body insulin resistance that can result in hyperglycaemia in those known to have diabetes, or the development of steroid-induced diabetes, which may or may not be transient.²

In 2014, colleagues at our institution audited glucocorticoid use and adherence to recommended glucose monitoring guidance.³ At that time 12.8% (n=120) of the inpatient population were on glucocorticoids with only 20.8% of those (n=25) having their glucose monitored. Of those 25 people, 13 had pre-existing diabetes. Since then, national guidelines on the management of hyperglycaemia and glucocorticoid therapy have been published.⁴ These guidelines recommended glucose monitoring regimens for those taking glucocorticoids. They stated that those who were known to have diabetes should have their glucose tested four times a day. Those without a diagnosis of diabetes should have either pre-lunch or pre-evening meal testing. If they develop a capillary glucose above 12.0 mmol/L, then testing should be four times a day.

We re-audited glucose monitoring in those adult inpatients on glucocorticoids at our institution on a single day in January 2020. We had 945 adult beds occupied on the day of the cross-sectional audit. Those with and without diabetes over 18 years old on glucocorticoids were identified using our patient administration system, electronic pathology system and electronic prescribing and medicines administration system (JAC^®, WellSky Ltd, Basildon, Essex, UK). We excluded those on the children’s ward, maternity wards or in the emergency department.

Table 1 shows the results, and compares them with the data from 2014. We found that 8.9% (n=84) of inpatients were receiving exogenous steroids. Of these, 48% (n=40) were having their glucose monitored. 87.5% (n=14) of those with diabetes were having four times a day testing. However, only 37% (n=25) of those with no previous diagnosis of diabetes were having the advised once daily glucose monitoring. We did not analyse which of these individuals should have been having four times a day testing, nor did we set out to identify any individuals with newly diagnosed diabetes or steroid-induced diabetes in those who were not known to have diabetes prior to admission.

This re-audit has shown some improvement in glucose monitoring of those taking steroids as an inpatient. However, it is still less than half of the target population and not in line with the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) guidance published in 2014. It is possible that the improvement in monitoring since our last audit is due to an increased awareness among medical and nursing staff of the impact of glucocorticoids on glucose concentrations and the potential consequences. However, this is just speculation.

This re-audit was undertaken because our institution had recently introduced electronic prescribing. The electronic platform allows alerts to be added when high-risk medications are used. Despite the poor performance in glucose monitoring shown by our previous audit, our pharmacy would not add an alert reminding those who were dispensing the glucocorticoids (ie, trained ward nurses) to conduct bedside capillary glucose monitoring unless we could show that it was not being carried out already in accordance with the JBDS-IP guidance adopted by our hospital. Despite the improvement in monitoring frequency, it remains suboptimal and, as a result of the current work, our pharmacy has agreed to introduce the alert once the pandemic has resolved. We aim to re-audit the impact of this in due course.

Conflict of interest Professor Dhatariya is one of the lead authors on the JBDS guideline entitled ‘Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group’.

References

1. British Medical Association, Royal Pharmaceutical Society of Great Britain. British National Formulary. London, 2020.

2. Geer EB, Islam J, Buettner C. Mechanisms of glucocorticoid-induced insulin resistance. Endocrinol Metab Clin North Am 2014;43:75–102. https://doi.org/10.1016/j.ecl.2013.10.005

3. Narwani V, Swafe L, Stavraka C, Dhatariya K. How frequently are bedside glucose levels measured in hospital inpatients on glucocorticoids? Clin Med 2014;14:327–8. https://doi.org/10.7861/clinmedicine.14-3-326a

4. Roberts A, James J, Dhatariya K, et al. Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group. Diabet Med 2018; 35:1011–17. https://doi.org/10.1111/dme.13675

Correspondence: Professor Ketan Dhatariya
Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK
E-mail: ketan.dhatariya@nnuh.nhs.uk

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Re-audit of bedside glucose monitoring of inpatients on glucocorticoids: have we improved?

References