November 18, 2010

Inhaled Cortisone Raises Risk of Diabetes By 34 Percent and Worsens Existing Cases

As someone who saw her marginal blood sugar control deteriorate dramatically and permanently after a single course of prednisone I know that cortisone can cause permanent damange to blood sugar control.

Years ago when I posted about this on the old board, several people sent me emails reporting that the same thing had happened to them. Prescription cortisones had either made them diabetic or, if they were diabetic but in good control, the cortisones had made their blood sugar control much harder, in some cases forcing them to use insulin.

My doctors have continued to tell me that the changes that cortisone makes in blood sugar are temporary. Now large study confirms that exposure to another form of cortisone, that found in the inhalers used to treat asthma and allergies, dramatically raises the risk of diabetes and worsens the blood sugar control of people who already have diabetes. The study is:

Inhaled corticosteroids linked to increases in diabetes incidence
Suissa S. Am J Med. 2010;doi:10.1016/j.amjmed.2010.06.019.

You can find an excellent summary of the study findings at Endocrinology Today here:

ET: Inhaled corticosteroids linked to increases in diabetes incidence

Here's the gist of the study as reported by Endocrinology Today:
The study cohort was composed of 388,584 patients, with 30,167 experiencing diabetes onset during a mean of 5.5 years of follow-up. Calculations put annual incidence rate at 14.2 per 1,000 patients.

Results also revealed that 2,099 patients progressed from oral hypoglycemic treatment to insulin, translating to an annual incidence rate of 14.2 per 1,000 patients for diabetes progression.

Data also linked inhaled corticosteroids with a 34% boost in the incidence of diabetes onset (RR=1.34; 95% CI, 1.29-1.39), although the greatest increase was seen among patients receiving the highest doses or the equivalent of at least 1,000 mcg of fluticasone daily.

Incidence of diabetes progression also rose with the current use of inhaled corticosteroids, with results indicating an RR of 1.64 (95% CI, 1.52-1.76). Again, the highest doses were associated with the greatest increase in incidence of diabetes progression (RR=1.54; 95% CI, 1.18-2.02).
These inhalers may be necessary for people with life-threatening asthma, and if you need one for that reason, you may just have to take the hit to your blood sugar.

But I know, from personal experience with family members, that doctors prescribe these powerful corticosteroid inhalers to people for mild allergies and bronchitis. In that case the risk involved is much higher than is justified by the relief the inhalers provide.

If you have a family history of diabetes, diabetes yourself, or know that you are insulin resistant, avoid these inhalers unless you need them to prevent severe asthma crises.

The same is true of all other forms of cortisone. Orthopedic surgeons will offer just about any one that comes into their office complaining of a sore joint a steroid injection, even in cases, like frozen shoulder, where the clinical evidence proves that these shots do nothing to speed up healing. My guess is that the surgeons do this because it makes the patient feel that they've done something to justify the whopping bill for the appointment.

Unfortunately, what these shots may also have done is damage your blood sugar control permanently. So think twice before you allow a large shot of any cortisone to be injected into your body.

Cortisone does not always cause permanent damage. The amount of the dose seems to be important, as the study above suggests. In most cases cortisone treatments will elevate blood sugar for a week or so and then the blood sugar will return to where it was before the treatment. The cortisone creams you apply to skin shouldn't raise your blood sugar at all, though over time if you over use them they will thin your skin.

Save cortisone treatments for the applications where they are appropriate--these are the conditions where it is necessary to turn off an out of control immune attack before it does serious damage. Cortisone helps in some difficult autoimmune conditions and can be lifesaving in others.

But for run of the mill pain and inflammation, like that from a stressed joint, torn tendon, or bad back, cortisone is overkill.

A huge review confirms that cortisone injections for tendon problems like frozen shoulder helps pain short term but yields worse outcomes middle and long term. In short, cortisone shots make it harder for tendon injuries to heal--while significantly raising the risk of diabetes (though the last wasn't explored in this particular study.)

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.
Brooke K Coombes et al. The Lancet , Volume 376, Issue 9754, Pages 1751 - 1767, 20 November 2010.doi:10.1016/S0140-6736(10)61160-9

If the problem is nerve pain, try a low dose of Tylenol.If the problem is inflammation use the lowest dose of a NSAID that works for you. Both these classes of drugs can be hard on your kidneys and liver if you take them too frequently so only take them when you really need to, and keep in mind the the less you use the better.

When my kids had fevers, I used to give them toddler sized doses of Tylenol until they were teens. They worked. The current trend is to package all these drugs in monster sized pills. Tylenol, which is effective in 325 mg pills, for example, is now sold mostly in 500 mg pills and caplets and in even larger sizes. Check the shelf for the small size pills, and start with a half tablet. Then work up to the dose that is effective. I often find half a Tylenol does the trick for my back pain.

There's a lifetime relationship between the total amount of Tylenol and NSAIDs you take and your risk of end stage kidney disease. So the less you take the better off you'll be, but there are times when you are in pain and they can be very helpful.

And if a doctor tries to prescribe any form of cortisone for you, do a bit of research on your own to find out if it really is appropriate. The saddest part about the prednisone that ruined my blood sugar control is that it was prescribed for something it had no chance of curing. The doctor gave it to me as is so often the case so he could say he'd done something rather than telling me the truth, which was that the condition I'd shown up with was one that would not respond to medical treatment.



Villa Priscilla said...

I left both Tylenol and ibuprofen behind and switched back to aspirin, taken with food. I need pain killers only rarely, now, it seems, but I have taken enough 'lifetime' Advil to sink a ship. Do you know if aspirin is a threat to kidney function?

Lori Miller said...

Scary. Is Flonase one of these medications? My doctor prescribed it for me for my continual nosebleeds. I started taking big doses of zinc instead and it pretty much stopped them.

Jenny said...

All I know about aspirin is that it can cause bleeding and irritate the stomach if taken in large doses. There's controversy about whether it helps women avoid heart attack and for people with low platelets taking it might increase the risk of stroke.

Jenny said...

Flonase is the brand name of fluticasone which is the drug mentioned in this study, so yes, it is.

Yours is a VERY good example of the way these drugs are abused by doctors. A steroid is not likely to stop bleeding and because they thin skin long term might make it worse.

Next time you're given a prescription, search on Google for it's generic name and read the Prescribing Information to find out what possible side effects it might have and what drug interactions. Drug interactions is a whole nother blog topic I need to cover. Doctors are frighteningly ignorant about them too.

Boz said...

I was dumb enough to take cortisone injections in my knee and shoulder, resulting in insulin dependence. No warning was given this might happen, but I should have known better. 20/20 hind site. Now my type 2 father was put on prednisone for temporal arteritis and had to go on insulin. Sad part is, he didn't have TA, but lymes disease. Months of suffering due to mis-diagnosis when we insisted he had lymes from the get go. The letters of apology from the clinic can't reverse the damage done, unfortunately.

Lori Miller said...

My mother tells me my aunt just had a cortisone shot for her sciatica and it raised her BG over 500 (yes, five hundred). Yikes!

I love my aunt and I've really, really tried to pass on to her the knowledge I've gained here and from other sites and from my mom's greatly improved BG control using this info. But since my aunt has a nutritionist, 20 years' experience as a diabetic, and an A1C of 6.3, I can't tell her anything.

Helen said...

Comment Part 1:

I read this with interest (make that alarm) when it was posted, since my daughter has had oral prednisone three times for acute asthma, and was on a course of twice-daily budenoside via a nebulizer during cold season for the past two years. And our whole family was on year-round intranasal corticosteriods, which I personally resisted taking until 2004, when I became convinced of their relative safety and found them to be nothing short of a miracle cure for my year-round allergic rhinitis, with incredibly miserable seasonal flare-ups often accompanied by asthma.

1) I did do research at the time we started each of these medications (except the predisone, which was not recommended or taken lightly) and didn't find anything concerning about glucose control or diabetes. Sometimes the study just hasn't been done yet.

2) For people who suffer from allergies and asthma, a little prevention with some steroids can prevent a pound of cure with more dangerous, systemic doses of steroids if symptoms are allowed to worsen. For instance...

* Treating eczema with topical steroids can prevent children from developing asthma. (Eczema should be prevented first by daily application of petroleum jelly, but if this doesn't work, a steroid cream should be used to treat flare-ups.)

* Treating allergic rhinitis with intranasal corticosteroids can also prevent asthma.

Those are the steroid treatments with the least systemic impact.

* Chronic asthma can effectively be controlled with inhaled corticosteroids. These are safer than long-acting bronchodilators or overuse of albuterol, and go a long way toward preventing the need for oral prednisone, which no one thinks is a great idea as a line of first defense.

* Prompt treatment of an asthma attack with oral prednisone, however, can prevent hospitalization. Hospitals are about the least healthy place to be and we all know that one's control over one's health choices is too easily lost in a hospital setting.

Helen said...

Comment Part 2:

At the time I read your post, Jenny, we had run out of our intranasal corticosteroids because I couldn't afford the steep copay. Your article gave me pause about refilling the prescriptions, which is good. I did a little more research and found that some intranasal corticosteroids are better than others. Budenoside gets absorbed into the system much more than fluticasone, and mometasone least of all (extremely little), which happens to be the type we were taking. (Daughters got a rash from fluticasone, which has the lower copay.)

My daughter hasn't had to resume her nebulizer treatments this year, but I think I'll get us back on the mometasone in the interest of quality of life and reducing the risk of asthma.

I have been inspired by your article to try harder with non-pharmacological remedies, such as saline spray and neti pots, and using allergen-neutralizing powders and sprays in the house, which I've never tried before. Generally speaking, the fewer chemicals we dump into our systems, the better.