Don’t practice medicine with blinders on

At the first clinic visit for a patient we obtain a medication history, and when we prescribe new medication we check for adverse drug interactions and give a brief overview of potential major side effects. Hopefully we review medication history at subsequent visits.

I received the following e-mail from a patient:

“Because of an encounter with poison ivy in my little raspberry patch last week, the dermatologist has put me on prednisone ... three tabs for five days, then two tabs for five days and then one tab for five days. Today is the fourth day of three tabs in the morning. The blood glucose is high ... 288 this morning, so naturally I am concerned about a two-week exposure to the drug. Can I continue safely, or should I reduce the dosage and prolong the time?”

The patient had type 2 diabetes treated with metformin, pioglitazone and glargine. He had worked hard to maintain his fasting glucose always below 120 mg/dL and mostly between 80 and 100 mg/dL, so you can imagine his concern with a value of 288 mg/dL.

Obtaining a history of diabetes should have been an essential component of his visit to the dermatologist. It is OK for the dermatologist not to be comfortable making recommendations for managing diabetes in a patient starting a short course of prednisone; it is not OK to ignore the diabetes altogether.

Of the three medications the patient is taking for his diabetes, the easiest to manipulate with respect to changing the dose is the glargine. On my return phone call to the patient (he deserved more than a replied e-mail), we discussed that evening’s dose and laid out plans for subsequent dose changes based on how much prednisone he was scheduled to take.

An important part of that call was to give reassurance that a short, two-week, tapering course of steroids should not have any long-term consequences for his diabetes. He should expect to return to his previous excellent glycemic control within a day or two after his last dose of prednisone. Then we can return to our ultimate goal of gradually reducing the need for all of his therapy for diabetes.