Editorial
Corticosteroids in diabetes and
chronic obstructive pulmonary
disease: a therapeutic balancing act
Gillian E Caughey*1 & Elizabeth E Roughead1
“...corticosteroids are not recommended in patients with
diabetes due to the potential for hyperglycemia,
subsequent poorer diabetes control and an increased risk
of disease progression.”
The presence of comorbid conditions in
older patients with diabetes adds consid-
erable complexity to therapeutic manage-
ment and care [1,2] , and may affect func-
tional capabilities and health outcomes
[3,4] . More than 50% of older diabetic
patients will have at least three comorbid
conditions [1,2] , with as many as 60% fac-
ing treatment conflict as a result [2] . Treat-
ment conflicts are difficult to manage as
there is often no or limited evidence-based
information to help guide clinicians. The
existence of chronic obstructive pulmonary
disorder (COPD) in those with diabetes
represents one of these conflicts and pres-
ents a therapeutic dilemma for clinicians
treating those patients. There are no ran-
domized trials that have assessed both the
outcomes of diabetes complications and
reduction in COPD exacerbations in older
patients with both conditions. COPD is a
common comorbidity in the older diabetic
population, with a reported prevalence of
between 10 and 20% [1,2] . Furthermore, of
the chronic conditions, COPD and diabe-
tes are both projected to be among the top
ten leading causes of mortality and burden
of disease worldwide by 2030 [5] .
COPD is a progressive lung condition,
characterized by a largely irreversible
1
Quality Use of Medicines & Pharmacy Research Centre (QUMPRC), Sansom Institute, School of Pharmacy & Medical
Sciences, University of South Australia, Australia
*Author for correspondence: gillian.caughey@unisa.edu.au
10.2217/DMT.13.39 © 2013 Future Medicine Ltd
airflow obstruction resulting in a cough
and dyspnea, along with acute exacer-
bations of these symptoms that often
require hospitalization [6] . The presence
of COPD in patients with diabetes is asso-
ciated with the reduced ability to perform
self-­management activities necessary for
optimal diabetes control and associated
therapeutic challenges [7] . Corticosteroids
are one of the recommended therapies for
COPD from international guidelines [8,9] ,
which poses a therapeutic dilemma for cli-
nicians who care for patients with diabetes
and COPD. “The presence of chronic
When considering diabetes guidelines obstructive pulmonary disorder
[101] , corticosteroids are not recommended in patients with diabetes is
in patients with diabetes due to the poten- associated with the reduced
tial for hyperglycemia, subsequent poorer ability to perform
diabetes control and an increased risk of self-management activities
disease progression [10,11,101] . However, necessary for optimal diabetes
optimal treatment of COPD with cortico­ control and associated
steroids in accord with current COPD therapeutic challenges.”
guideline treatment recommendations is
likely to place the patient with comor-
bid diabetes at increased risk of diabe-
tes complications and poorer long-term
health outcomes. While the treatment
and prevention of COPD exacerbations is
a priority, this needs to be balanced with
managing long-term diabetes outcomes.
part of
Diabetes Manage. (2013) 3(5), 353–355 ISSN 1758-1907 353
Editorial  Caughey & Roughead
Corticosteroids are commonly prescribed
in people with diabetes and COPD, with at
least 60% of patients using corticosteroids [12] .
Further­more, over 70% of patients with COPD
are reported as using inhaled corticosteroids,
despite being the subject of much debate [13] . In
large clinical trials for COPD, inhaled corticoste-
roids have been shown to reduce the frequency of
exacerbations (particularly for those with mod-
erate-to-severe COPD) and improve quality of
life, but have not been shown to improve lung
function or reduce mortality [6,14] . These trials
used higher doses of inhaled corticosteroids and
data on lower doses are lacking [6] . Treatment
of acute exacerbations with oral corticosteroids
provides symptomatic relief, improves lung func-
tion and dyspnea and reduces hospital stay time
[6,15] . However, given the range of adverse effects
associated with systemic corticosteroid therapy,
the optimal dose and duration of oral cortico-
steroid treatment needs to be better defined [15] .
These studies need to be conducted, not only in
those with COPD, but also in the presence of
comorbidity.
Unfortunately, there is not a lot of incentive
in the regulatory world to undertake these types
of studies in real-world populations. Observa-
tional studies play an important role in support-
ing the evidence base for the safety and efficacy
of medicines, particularly for older patients
and those with comorbidity who are generally
excluded from randomized clinical trials [16] .
Recent observational studies have been able to
shed some light on this important therapeutic
dilemma. Two large cohort studies in Canada
and Austrailia examined whether corticosteroids
exert a dose-dependent effect on diabetes inci-
dence, progression and complications in those
with COPD [12,17] .
“...given the range of adverse effects
associated with systemic corticosteroid
therapy, the optimal dose and duration
of oral corticosteroid treatment needs
to be better defined.”
The Canadian-based population study of
388,584 patients with respiratory disease showed
that treatment with inhaled corticosteroids was
associated with a 34% (rate ratio: 1.34; 95% CI:
1.29–1.39) increased risk of diabetes onset, with
the higher doses of corticosteroids (fluticasone
1000 µg/day or more) associated with the great-
est risk [17]. In a subset of patients with respiratory
354 Diabetes Manage. (2013) 3(5)
disease and newly treated with oral hypoglycemic
agents, inhaled corticosteroid use was associated
with a 34% (rate ratio: 1.34; 95% CI: 1.17–1.53)
increased risk of progression to insulin use,
again with higher doses associated with greater
risk (54%) [17] .
“Corticosteroids are commonly
prescribed in people with diabetes and
chronic obstructive pulmonary disorder,
with at least 60% of patients using
corticosteroids.”
We conducted an Australian study in older
people with COPD and diabetes, examining the
risk of diabetes complications with corticosteroid
treatment. This study demonstrated that higher
doses of corticosteroids, equivalent to an average
daily dose of corticosteroids for at least 10 months
over a 1‑year period, was associated with a 94%
(subhazard ratio: 1.94; 95% CI: 1.14–3.28;
p = 0.014) increased risk of hospitalization for
a diabetes complication (predominantly micro­
vascular complications) [12] . This increased risk
was not evident for the lower doses. We only
included new users of diabetes medicines and,
therefore, they were unlikely to have any pre-
existing diabetes complications. Our study con-
firms the Canadian findings of the potential for
adverse diabetes outcomes with the use of high
doses of corticosteroids in patients with diabetes
and COPD.
The results of these studies highlight the need
to determine optimal dosing of corticosteroids
in patients with the comorbidity of COPD and
diabetes. Clinical trials to date have only exam-
ined corticosteroid use in the COPD population;
comorbid patients have been excluded. To
advance the evidence base we need to understand
the magnitude of risk, the relationship of total
dose, duration and cumulative exposure on risk
with use of corticosteroids, to facilitate improved
health outcomes for patients, particularly in the
setting of comorbidity. More research is needed
to fill this gap by monitoring health outcomes
for both diabetes and COPD. Our studies,
while assessing diabetes complications, did not
determine the impact of lower doses of cortico-
steroids on COPD outcomes. In the interim,
clinicians should be striving to use the lowest
dose possible for the shortest period of time that
will maximize COPD benefit without trading
off diabetes outcomes. High doses of cortico-
steroids should be avoided where possible, but if
future science group
 Corticosteroids in diabetes & chronic obstructive pulmonary disease: a therapeutic balancing act  Editorial

unavoidable, should be limited to shorter term
use. A recent randomized controlled trial dem-
onstrated that use of a 5-day treatment with oral
corticosteroids in patients hospitalized with an
acute exacer­bation of COPD was noninferior to
a 14-day course with regards to re-exacerbation
[18] . This significantly reduces corticosteroid
exposure [18] and may be particularly appropri-
ate for the comorbid population. To facilitate
the therapeutic balancing act with corticoste-
roid use in patients with diabetes and COPD,
regular review of efficacy and use of a minimally
effective dose, together with close monitoring of
blood glucose levels to ascertain whether diabetes
therapy needs to be intensified, is recommended.
It is also imperative to consider that patients
differ in health preferences and priorities when
confronted with such trade-offs, which should
be taken into account [19] . Given the fact that
different medical special­ities may be involved in
the treatment of these competing conditions, the
need for shared decision-­making and consensus
prescribing models should be considered.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert t­estimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.

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