Dexamethasone and Type 1 Diabetes
Myron Yaster MD, Jennifer Hamrick MD, and Lynne G. Maxwell MD
“Approximately 1 of every 300 children in the United States has type 1 diabetes mellitus (T1D), and these patients may require anesthetics for a variety of procedures. Perioperative coordination is complex, and attention to perioperative fasting, appropriate insulin administration, and management of hypo- and hyperglycemia, as well as other metabolic abnormalities, is required. Management decisions may be impacted by the patient’s baseline glycemic control and home insulin regimen, the type of procedure being performed, and expected postoperative recovery. If possible, preoperative planning with input from the patient’s endocrinologist is considered best practice.”1
Despite its widespread prevalence and importance, as I was reading today’s PAAD by Katerenchuk et al.2, I discovered much to my chagrin, that we’ve never had a PAAD on type 1 diabetes management! And today’s PAAD addresses a question I had always wondered about, namely what if any impact does dexamethasone, used almost universally in PONV management, have on blood glucose levels? Is it safe? Should we avoid it? Do the benefits outweigh the risks? Today’s PAAD is systematic review of the ADULT literature attempting to answer this question. For a deeper dive and review of the perioperative management of type 1 diabetes, our executive council member and editor-in-chief of OpenAnesthesia, Dr. Dabe Chatterjee, recommends the following 2 OpenAnesthesia articles.
https://www.openanesthesia.org/keywords/perioperative-management-of-patients-with-type-1-diabetes-mellitus/
https://www.openanesthesia.org/keywords/glucose-homeostasis-and-insulin-therapy/
I couldn’t find a similar study or really any study looking at the impact of dexamethasone on glycemic control in pediatric Type 1 Diabetic patients in the pediatric anesthesia literature. I did find a study of adults with type 2 diabetes who received dexamethasone, which found that dexamethasone increases postoperative blood glucose levels in both non-diabetics and diabetics.3 Thus, this lack of data and guidance is an opportunity for one of you or the SPA community to study this! Myron Yaster MD
Original article
Katerenchuk V, Ribeiro EM, Batista AC. Impact of Intraoperative Dexamethasone on Perioperative Blood Glucose Levels: Systematic Review and Meta-Analysis of Randomized Trials. Anesth Analg. 2024 Sep 1;139(3):490-508. doi: 10.1213/ANE.0000000000006933. Epub 2024 Aug 16. PMID: 39151135.
Original review article
Martin LD, Hoagland MA, Rhodes ET, Wolfsdorf JI, Hamrick JL; Society for Pediatric Anesthesia Quality and Safety Committee Diabetes Workgroup; Society for Pediatric Anesthesia Diabetes Workgroup members. Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus, Updated Recommendations for Anesthesiologists. Anesth Analg. 2020 Apr;130(4):821-827. doi: 10.1213/ANE.0000000000004491. PMID: 31688079.
Dexamethasone is a potent glucocorticoid used almost ubiquitously in pediatric anesthesia as an adjunct to prevent or minimize post operative nausea and vomiting (PONV). As a glucocorticoid it increases blood glucose levels via hepatic gluconeogenesis and increased insulin resistance. Thus, is it safe to use in type 1 diabetics?
Katerenchuk et al.2 “searched CENTRAL, MEDLINE, and clinicaltrials.gov for randomized controlled trials (RCTs) comparing a single intraoperative dose of dexamethasone to control in adult patients who underwent noncardiac surgery. The primary outcomes we assessed maximum blood glucose levels measurement and variation from baseline within 24 hours of surgery; blood glucose levels measurement and variation from baseline at 2, 4, 8, 12, and 24 hours after dexamethasone administration. As secondary outcomes, we evaluated insulin requirements and hyperglycemic events.”2 They found that “perioperative dexamethasone can cause an elevation in blood glucose levels, with no difference being shown between different doses (4–5 mg vs 8–10 mg) and diabetic status. Mean blood glucose levels rise between 0.37 and 1.63 mmol L −1 (6.7 and 29.4 mg dL −1 ) within 24 hours after a single dose of dexamethasone administered at induction of anesthesia compared to control, but in most patients this difference will not be clinically relevant.” In other words this is probably much ado about nothing!
“Timing of maximum blood glucose was not consistent among studies, but it usually occurred between 4 and 12 hours and could remain elevated for 24 hours. At 24 hours, the difference between groups remained significant, so we cannot assess at which timepoint this difference vanishes.”2 Finally, “higher dose administration of dexamethasone (8–10 mg) was not associated with higher blood glucose levels than lower dose (4–5 mg) in all timepoints, with the exception of 24 hours after administration.”2
Our take home message is that for most diabetics, the small increase in blood glucose following perioperative dexamethasone administration is much less important than the PONV benefits. On the other hand, patients who are already hyperglycemic and who receive dexamethasone may have to adjust their insulin dosing perioperatively.
What do you do in your practice? Have you or will you consider the effects of dexamesthasone in your anesthetic plans? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Martin LD, Hoagland MA, Rhodes ET, Wolfsdorf JI, Hamrick JL. Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus, Updated Recommendations for Anesthesiologists. Anesthesia and analgesia 2020;130(4):821-827. (In eng). DOI: 10.1213/ane.0000000000004491.
2. Katerenchuk V, Ribeiro EM, Batista AC. Impact of Intraoperative Dexamethasone on Perioperative Blood Glucose Levels: Systematic Review and Meta-Analysis of Randomized Trials. Anesthesia and analgesia 2024;139(3):490-508. (In eng). DOI: 10.1213/ane.0000000000006933.
3. Tien M, Gan TJ, Dhakal I, et al. The effect of anti-emetic doses of dexamethasone on postoperative blood glucose levels in non-diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia 2016;71(9):1037-43. (In eng). DOI: 10.1111/anae.13544.