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Diabetes is nothing to sneeze at
A common cold can have surprising effect on blood sugar level.
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Last fall, I saw a 51-year-old man in follow-up for steroid-exacerbated insulin-requiring type 2 diabetes.
He had missed his last few appointments. The patient had been treated with 5 mg of prednisone daily for the past few months for autoimmune hepatitis.
He reported a cough that had started two days prior to the visit. He had also noticed a drastic increase in his blood glucose levels. His fasting range was usually 146 mg/dL to 200 mg/dL, but was recently in the low 300s. His postprandial range was usually in the high 100s and low 200s, but over the past two days was in the high 200s and low 300s. His blood glucose level in my office was 364 mg/dL, which was three hours after his last meal.
The patient had no diabetes complications. However, he was suffering from hypertension, hyperlipidemia and obesity, as well as autoimmune hepatitis. Other medical history consisted of pancreatic pseudocyst, nasal septum repair, cholecystectomy and a motor vehicle accident. His weight had been increasing steadily since initiating steroid treatment one year prior to seeing me.
Review of systems was unremarkable, with the exception of a nonproductive cough and mild rhinorrhea.
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Medications included levemir (Insulin-Detemir, Novo-Nordisk) 60 U in the morning and 70 U at night; aspart 30 U to 45 U with meals (he had been trained to count carbohydrates, but was using his own parameters for dosing); and prednisone 5 mg daily.
The patient was an accountant, had quit smoking 10 years ago, was not drinking alcohol and had a family history positive for type 2 diabetes in his father. Pertinent physical exam showed a blood pressure of 136/80 mm Hg, pulse 84, height 6’ 2”, weight 385 lb, BMI 49.4.
He was afebrile and his general appearance was alert, with no distress, and he was cooperative. He had moist mucus membranes, erythematosus oropharynx, and no exudates. He did not have a heart murmur, rubs or gallops. S1 and S2 were normal, and S3 and S4 were absent. His lungs were clear to auscultation bilaterally with no crackles. The patient’s skin color, texture and turgor were normal; there were no rashes or lesions. His last LDL was 88, HbA1c was 8.4%, and microalbumin was 3.3 in February of 2008.
In addition to starting the patient on an antihypertensive regimen and reviewing his insulin regimen, in light of possibly changing steroid dosages and poorly implemented carbohydrate counting, you wonder about the sudden increase in blood glucose levels.
Which mechanism would not explain the sudden change two days prior to the visit?
A. The patient was acutely sick with an infection.
B. The patient may have been using insulin that was inappropriately stored or past its usable date.
C. He may have started taking a higher dose of corticosteroids.
D. He had a piece of cake three days prior to the visit, and its effects were still noticeable.
E. He was treating his cold but worsening his diabetes.
CASE DISCUSSION:
Hyperglycemia is frequently seen in patients with diabetes. Even an otherwise harmless upper respiratory tract infection can increase blood glucose levels significantly for a few days (A). Blood sugar improves with spontaneous resolution of the infection or with treatment.
Another reason for sudden increases in blood sugar levels is inappropriately stored or outdated insulin (B). This scenario is particularly concerning in patients with type 1 diabetes and in patients who increase their doses, only to experience hypoglycemia when they start a new batch of insulin.
Communication about the proper steroid dosing between practitioners is paramount, as requirements can change with the clinical picture, and insulin dosages need to be adjusted. A higher steroid dose can certainly be the cause of a sudden increase in blood sugar levels (C). One single piece of cake may affect the course of the day or perhaps even the next morning, but would not be likely to affect blood glucose levels three days later (D).
In this case the patient was kind enough to offer me a cough drop. He had consumed three of them over the course of his 20-minute visit. We quickly established that he was consuming almost 50 cough drops per day, at 4 g carbohydrates per cough drop (Answer is E). He was amazed when I told him that the cough drops were increasing his blood sugar levels and that there were sugar-free cough drops available in stores for patients with diabetes.
Cough syrups are similarly notorious for raising blood sugar levels, and clinicians should make sure that patients know about the availability of diabetes-friendly versions.
Ronald Tamler, MD, PhD, MBA, is an Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, N.Y.