#483: Diabetic Dilemmas in Older Adults, Pregnancy and Corticosteroid Use with Jeff Colburn, MD

May 19, 2025 | By Isabel Valdez

Audio

Video

Transcript available via YouTube

This episode doesn’t sugarcoat the truth about tricky diabetes management!

Wrangle wild blood sugars among older adults, pregnant individuals, and those taking corticosteroids! Join our Kashlak resident endocrinologist Dr. Jeff Colburn, as we dive into diabetic dilemmas. We will help you dodge dangerous lows and navigate tricky treatment traps in these special populations. Get the un-sugar-coated truth on managing complex diabetes cases! 

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Show Segments

• Intro
• Diabetes in Older Adults (Geriatrics)
  • General Approach
  • Risks of Hypoglycemia
  • 4Ms Framework
  • Insulin Management
  • Oral Medications
• Diabetes in Pregnancy
  • Preconception Counseling
  • Eye Health Monitoring
  • Insulin Therapy During Pregnancy
  • Postpartum Care
• Steroid-Induced Hyperglycemia
  • General Approach
  • Postprandial Insulin Adjustment
  • NPH Insulin Usage
  • Initiating Insulin
  • Role of GLP-1RA and SGLT2-inhibitors
• Take-home Points
• Outro

Disclosures

Dr. Jeff Colburn reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

The Diabetic Dilemmas in Older Adults, Pregnancy and Corticosteroid Use –  Pearls

1. Older Adults–
   1. Hypoglycemia can harm older patients by worsening cognitive decline and impacting their mobility
   2. Consider relaxing HbA1c goals to 7-8% based on life expectancy/co-morbidities, in order to reduce risks from hypoglycemia
   3. Simplify medication regimens to minimize polypharmacy burden and hypoglycemia risk.
2. Pregnancy–
   1. Glucose readings are falsely low in pregnancy; Aim for stricter glycemic control during pregnancy; (HbA1c <6%, fasting 70-95 mg/dL, postprandial 100-120 mg/dL). Insulin is the preferred first-line agent, as others may cross the placenta.
   2. Screen for diabetic retinopathy in the first trimester of pregnancy, and potentially each trimester if concerns arise, as pregnancy can affect eye health.
   3. Preconception counseling should include tight glucose control before pregnancy and contraception if the patient is not ready to become pregnant.
   4. Help patients lose weight and control the blood glucose in postpartum (and once they’re done breastfeeding) with GLP-1 receptor agonists (GLP-1RA). 
3. Steroid-Induced Hyperglycemia– 
   1. Corticosteroids primarily raise postprandial glucose levels. Consider using intermediate-acting NPH insulin, which can align better with steroid onset/duration of action, and consider mealtime rapid-acting insulin.
   2. A practical approach for starting NPH insulin with prednisone is 0.1 units/kg for every 10mg of prednisone, up to a maximum of 0.4 units/kg for 40mg or more.
4. Continuous Glucose Monitors (CGMs) are valuable tools across all of these populations.
5. GLP-1RA can be beneficial add-on medications, especially for weight management post-pregnancy or with steroid use, while SGLT2 inhibitors can help manage postprandial spikes.

The Diabetic Dilemmas in Older Adults, Pregnancy and Corticosteroid Use — Show Notes

Diabetes in the Older Population

General Approach

Start by confirming the type of diabetes that the patient has with appropriate labs.  Many older adults have type 2 diabetes that depends on insulin because beta cells lose function over time. 

Treatment Goals and Risks of Hypoglycemia

Cognitive impairment can impact an individual’s ability to reliably assess or track glucose readings, therefore be aware of hypoglycemia risks or confusion regarding changing treatment plans.

Older adults with diabetes and complex health issues exhibit diverse health profiles and varying life expectancies. Therefore, individualized glycemic targets are crucial; less strict goals may be appropriate for older adults with significant cognitive or functional impairments, frailty, severe co-existing conditions, and when the risks of intensive diabetes treatment outweigh the benefits (ADA, 2024).  Help the patient and family understand that it is not necessary to chase a lower HbA1c due to the risks such as hypoglycemia. Hypoglycemia worsens cognitive function and increases the risk of falls; both of these are detrimental to the older adults’ independence (Lee et al 2018). 

Hypoglycemia Rule of 15s Flashback

Diabetes and  4Ms Framework for Older Adults 

The 4Ms Framework for Age-Friendly Care (IHI 2025) is a useful way to approach caring for older adults with diabetes:

Mentation:  Assess cognition: can the patient assess and respond to their own hypoglycemia?

Medication:  Reconcile medications to avoid polypharmacy or adverse affect on comorbidities

Mobility:  Diabetic foot complications, fall risk, frailty and sarcopenia could impact mobility

What Matters Most: Discuss the patient’s long term care goals and how treatment impacts these goals

Bonus M– Multi-Complexity:  Consider comorbidities when making decisions that impact diabetes treatment. 

Insulin

Dr. Colburn’s expert approach in older adults needing insulin is to simplify the regimen to minimize hypoglycemia. 

• Long-acting insulin strategy: he may increase long-acting 0.2 to 0.3 units/mg/dL in older adults to optimize a once a day insulin dose. 
• Mealtime: Consider reducing the mealtime insulin from 2-3 times a day to just the largest meal of the day.  Mealtime correction can be challenging– to assess for a patient’s ability to correctly perform this calculation, have the patient recall the insulin correction you are recommending or give them test scenarios where they’d have to apply the corrections.  If the patient cannot reliably recall or apply the necessary correction to your test scenarios, insulin correction might not be the best approach. 
• Continuous glucose monitors (CGMs): CGMs in older adults are excellent tools that can help inform the patient, family, caregivers and providers on the patient’s day to day progress.   More detail on how CGMs can be used in management can be found in our episode CGMs, Insulin and How to Adjust to Diabetes Meds to Glucose Patterns.

Oldies but Goodies: Oral Medications to Keep in Mind

Sulfonylureas pose a significant risk of hypoglycemia but could be convenient and affordable options if used cautiously.  Meglitinides (repaglinide and nateglinide) and glipizide as mentioned in the ADA Standards of Care, all have a shorter duration of action which makes them more favorable options. DPP4-inhibitors, such as sitagliptin, have a small HbA1c reduction effect of 0.4% to 0.5%.  These have to be renally dosed and with careful initiation, some experts will try higher doses with careful monitoring (Mann and Muskiet, 2021). These have a side effect profile that is akin to a mild GLP-1RA and if affordable, these may help patients maintain or achieve a small HbA1c drop. Lastly, pioglitazone, the only available TZD in the US market, could help reduce the HbA1c by one point but due to their risk of fluid retention, this medication may not be the best choice for patients with heart failure (Erdmann et al, 2007).  These should also be avoided in patients with osteoporosis (Azhari and Dawson, 2025). Those concerns aside, Dr. Colburn mentions these agents may have a role in reducing the risk of stroke as noted in the IRIS trial (Bath et al, 2016; Spence et al. 2022) or may delay the onset of cognitive loss (Yen et al, 2023).  Patients with metabolic associated steatohepatitis may benefit from TZD because these medicines move visceral fat from the liver (Panunzi et al, 2021). 

Pregnancy and (all of the types of) Diabetes

Preconception counseling

Dysglycemia can affect pregnancy;  for this reason, the ADA recommends preconception counseling that encourages good glycemic control.  Teach patients of child-bearing age to discontinue GLP-1 receptor agonist and SGLT2 inhibitors should they become pregnant and encourage contraception if they are not ready to become pregnant. 

The A1c goal is less than 6% because of increased red blood cell turnover and higher amounts of intravascular fluids. 

Keep an Eye on GLP1-RA and Retinopathy

Pregnancy can affect eye health, so closely monitor pregnant patients’ eyes. Recent research links GLP-1RA use to nonarteritic anterior ischemic optic neuropathy and ischemic optic neuropathy (Abbass et al, 2025), and this risk extends beyond those who can become pregnant. Guidelines recommend annually routine  dilated eye exams to assess the retina in all patients and for pregnant individuals, our expert suggests retinopathy screening in the first trimester and potentially each trimester if concerns arise.

Treatment with Insulin in Pregnancy

In the past, metformin and sulfonylureas were used in pregnancy but these are no longer first-line use agents because they cross the placenta and children exposed to these medications have higher rates of metabolic dysfunction (Toft and Økland, 2024).  

The ADA now recommends insulin as the first line agent for glycemic control in pregnancy, especially because pregnancy can trigger more insulin resistance and higher risk of diabetic ketoacidosis (DKA) (ADA, 2025). Patients who have type 1 diabetes continue their insulin regimen and the treatment for type 2 diabetes should be changed to insulin.  Individuals who develop gestational diabetes (GDM) should be treated with lifestyle modifications. Treating GDM with insulin is the next guideline-mediated step if needed to achieve the recommended glycemic goals.  Starting insulin in pregnancy is similar to insulin initiation in the non-pregnant population with the only difference being that pregnant individuals need sooner and perhaps more frequent follow-up.  

Guidelines recommend starting basal insulin in GDM if hyperglycemia persists with lifestyle modifications (ADA, 2025).  However, Dr. Colburn’s expert suggestion is to get a glycemic profile on pregnant patients with fasting, pre- and post-prandial glucose readings to determine if insulin is needed around mealtimes more urgently and before basal insulin is needed. 

Postpartum care: It’s Not Over With Delivery

Patients with GDM have a 50% greater chance of developing type 2 diabetes five years postpartum; this in part due to an increase in insulin resistance following the surge of growth hormones that are released during pregnancy (Bengtson et al 2021).   Dr. Colburn recommends continuing insulin until the patient stops breastfeeding, followed by weight loss with either lifestyle changes or medications such as GLP-1RA.

Steroid-induced hyperglycemia

General approach

While we are aware that corticosteroids increase glucose levels in general, the effect of corticosteroids is seen more in postprandial glucose readings.   With that in mind, Dr. Colburn shares his expert approach to addressing hyperglycemia. 

Postprandial Insulin Adjustment

If the patient is already taking a rapid-acting insulin with meals, one suggestion is to increase this insulin by 10% to 20%.   He reminds us that insulin is cleared by the kidneys; if a patient has kidney disease, rapid-acting insulin doses could get stacked overtime, thereby causing hypoglycemia.  

From Long-acting Basal to Intermediate-acting NPH

Unlike long acting basal insulin which is mostly flat, neutral protamine Hagedorn (NPH) insulin is an intermediate-acting basal insulin that has a peak that might align with the postprandial hyperglycemia triggered by prednisone, methylprednisolone or hydrocortisone.   NPH insulin has an onset of 2 to 4 hours, peaks within 4 to 10 hours, it can last up to 18 hours.   To convert from long-acting insulin to NPH, Dr. Colburn instructs patients to administer ⅔ of the long-acting dose in NPH in the morning and the remaining 1/3 with dinner. If the patient is on dexamethasone, adjusting long-acting basal insulin alone may address the hyperglycemia without converting to NPH.

Starting Insulin for the First Time

In their 2009 article, Clore and Thurby-Hay developed an approachable strategy for adjusting NPH insulin based on the amount of prednisone being administered.  They recommend dosing NPH 0.1 units/kg for prednisone 10mg and increasing incrementally by 0.1 units/kg for every additional 10mg with a maximum dose of NPH 0.4 units/kg.  For example, one could start NPH 0.2 units/kg for prednisone 20mg, NPH 0.3 units/kg for prednisone 30mg,  and max out at NPH 0.4 units/kg for prednisone 40mg or more. 

A Place of GLP-1RA and SGLT2-inhibitors

GLP-1 receptor agonists primarily lower postprandial glucose levels and can be used alongside insulin, although their full effect takes several weeks. Consider their use as an add-on therapy, particularly for patients on long-term corticosteroids. SGLT2 inhibitors are another option, provided the patient’s kidney function is stable or improving.

Take-home Points

General

• CGM are useful in all patients particularly if they are on insulin. 
• GLP-1RA agents are great add-ons in these patient populations, especially those needing to achieve weight loss after pregnancy or with steroid-use. 
• SGLT2 can be used to help with postprandial glucose spikes. 

Older Adults

• Be careful with hypoglycemia in older adults. These adults might not detect low glucose reliably and they could fall in trying to treat low glucose. Hypoglycemia could also worsen cognitive decline. 
• Treatment plans can be less aggressive as they aim to meet a looser HbA1c goal.
• Avoid burdensome polypharmacy whenever possible.
• Align care plans with the  patient’s values,  quality of life and lifespan. 

Pregnancy

• Treatment goals are lower with HbA1c of 6% along with lower fasting and postprandial targets.
• Insulin is the treatment of choice in pregnancy. 
• Pre-pregnancy counseling should include regular retinopathy screening, good glucose controls and contraception if they’re not ready for pregnancy.
• Once a patient is pregnant, be sure to continue retinopathy screening starting at the first trimester.

Steroid-induced Hyperglycemia

• Insulin is an adjustable tool to use which you can add or optimize with hyperglycemia.
• Add NPH Insulin to your arsenal; administer 0.1 units/kg of NPH for every 10mg of  prednisone equivalent (with a max of 0.4 units/kg prednisone equivalent of 40mg or more) at the time that steroid is taken. 
• NPH insulin could be added to the patient’s treatment regimen or basal insulin could be converted to twice daily dosing of NPH insulin.

Links and Picks of the Week

The American Diabetes Association The Standards of Care in Diabetes
The American Diabetes Association  Standards of Care in Diabetes—Older Adults 2025	The American Diabetes Association Standards of Care in Diabetes — Pregnancy 2025	The American Diabetes Association Standards of Care in Diabetes Care in the Hospital 2025

Books by Jack E. Lewi
Be Well	Keys to Better Healthcare: A Guide for Patients and Healthcare Professionals	Rooted in Wellness: Exploring the Health Benefits of Trees

Paul and Jeff’s Favorite: The Steven Saylor Collection
Roma	Empire	Dominus

The Colburn Curbsider Collection
Curbsiders #397: Insulin, Type 2 Diabetes, Fanny Packs, and Hypoglycemia with Dr. Jeff Colburn	Curbsiders #433 CGMs, Insulin and How to Adjust Insulin to Glucose Patterns

Goal

Listeners will structure a framework to address unique challenges in managing diabetes in older adults, pregnant patients, and those with steroid-induced hyperglycemia

Learning objectives

After listening to this episode listeners will…

• Individualize glucose treatment goals for older adults, pregnant patients, and patients on corticosteroids
• Optimize diabetic medications, including insulin, to address labile glucose changes while preventing hypoglycemia. 
• Anticipate and mitigate complications that stem from hyperglycemia in aging patients, pregnancy and patients treated with steroids. 
• Implement current technologies and best practices to improve medication burden and enhance the quality of life of older adults, pregnant patients and steroid-dependent patients 

Citation

Valdez I, Colburn J, Williams PN, Watto MF. “#483: Diabetic Dilemmas in Older Adults, Pregnancy and Corticosteroids”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date May 12, 2025.

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