Steroids, Sugar Spikes and Management Strategies

JR is 64 years old, in hospital with type 2 diabetes and COVID. JR normally manages their diabetes with metformin, but during this inpatient stay, JR is on prednisone therapy which has spiked sugar levels into the 250 mg/dl to 350 range. JR is receiving bolus insulin sliding scale with meals and bedtime glargine, but blood sugars are persistently elevated. To improve outcomes for JR, it is important to keep blood glucose levels less than 180 mg/dl, but what should we recommend to get glucose to goal?

What are some strategies to get blood sugar to target while on steroids?

There is no consensus on the best approach to manage this situation. Up until this point in history, steroid-induced hyperglycemia was mostly found in people with diabetes in COPD, those undergoing chemotherapy or in post-transplant situations.

Oral Meds plus an Old Friend

With the COVID pandemic, many people with diabetes in hospitals and at home, are on steroids. Health care professionals are trying to figure out how to lower glucose levels.

For people with type 2 diabetes and COVID, the latest research indicates that sitagliptin (Januvia) not only helps maintain blood glucose but also decreases the inflammatory response associated with COVID infections. If not contraindicated, sitagliptin can be used in conjunction with insulin, to treat the extreme insulin resistance and hyperglycemia caused by steroid therapy.

To treat steroid induced hyperglycemia, we are going to call on our old insulin friend, NPH. Neutral Protamine Hagedorn (NPH) is an intermediate acting basal insulin. NPH insulin is made by mixing regular insulin and protamine in exact proportions with zinc and phenol such that a neutral-pH is maintained and crystals form.

NPH insulin’s peak action time matches steroid’s action time

NPH insulin is cloudy and has an onset of 1–4 hours. Its peak is 6–10 hours and its duration is about 10–16 hours.

Steroids have their highest potency at 4-12 hours, with the exception of the very potent dexamethasone, which has a half life of 1-2 days.

However, with all steroids, including dexamethasone, people will experience elevated glucose values after breakfast, lunch, dinner, and at bedtime but will have a significant drop toward normal glucose overnight.

Therefore, hyperglycemia is greatest 1–2 hours after a meal, with persistent elevation until the following meal, followed by a return to normal overnight.

NPH Insulin Dosing Strategies

There are several articles (see below) that recommend a variety of NPH dosing strategies. Generally, insulin dosing is based on a combination of steroid dose and body weight. For those on lower dose steroid (ie less than 40 mg prednisone daily) a starting NPH insulin dose of 0.1 – 0.2 units per kg is reasonable. If JR weighs 100 kg, that means 10 to 20 units of NPH daily.

If JR is on a higher steroid dose, or blood sugars are extremely elevated, JR may need 0.3 units/kg or 30 units of NPH daily. Of course, we also need to keep nutritional status in mind as we determine best dose. People who are not eating or NPO, will require less insulin, even in the presence of steroids.

The timing of NPH administration matches the timing of the steroid therapy.

In addition, coverage for carbohydrates at meals and correction insulin bolus for hyperglycemia can help prevent post-prandial hyperglycemia.

A simple getting started strategy – 70/30 Insulin

A simple strategy I have used over many years, that I find safe and effective, is giving the basal-bolus premixed 70/30 insulin with the morning dose of steroid. A safe starting range is around 10 units in the morning and gradually increases 10-20% daily to get glucose to target. In addition, bolus coverage for carbs and hyperglycemia can be given at lunch and dinner.

Since blood sugars trend down overnight, nighttime NPH insulin is not usually needed.

Keeping it flexible

As the person starts recovering and steroid doses are gradually tapered down, it is important to also decrease the NPH insulin dose and bolus insulins to prevent hypoglycemia.

In conclusion:

Keeping blood sugars on target improves outcomes. For people with diabetes, steroids can cause a hyperglycemic crisis. Thoughtful and progressive management using NPH and bolus insulins can turn the tide and help get blood glucose levels to goal.

Join Coach Beverly at our Virtual Conference for more information on COVID and Diabetes Management Strategies.

Reference Articles

Glycemic Control in Hospitalized Patients with Diabetes Receiving Corticosteroids Using a Neutral Protamine Hagedorn Insulin Protocol: A Randomized Clinical Trial. Khowaja A, Alkhaddo JB, Rana Z, Fish L. Diabetes Ther. 2018 Aug;9(4):1647-1655.

How to Manage Steroid Diabetes in the Patient With Cancer
David S. Oyer, MD, FACE, Ajul Shah, BS, and Susan Bettenhausen, APRN, CDE, 2006

Virtual DiabetesEd Specialist Course
Earn 30+ CEs | April 15-17, 2021


Virtual DiabetesEd Specialist Program

Whether you are new to diabetes or a seasoned expert, you’ll benefit from this virtual conference with the latest research plus critical content that you can immediately apply to your clinical practice.

DiabetesEd Virtual Conference Flyer 2021

Diabetes Ed Virtual 3-Day Schedule 2021

Prepare for CDCES or BC-ADM certification or earn hours for renewal.

If you are interested in taking the CDCES or BC-ADM exam or are seeking a state of the art review of current diabetes care, this course is for you. Our team has been fine-tuning this course for over fifteen years, and we know what you need.

Can’t join live? No worries, your registration guarantees access to the recorded content through Dec 31, 2021!

Team of expert faculty includes:

  • Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES – Educator of the Year, 2020
  • Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM
  • Ashley LaBrier, MS, RD, CDCES, Diabetes Program Coordinator

In addition to informative lectures, we also use group activities and case studies to highlight the essential knowledge, skills, and strategies needed to succeed in diabetes education today! 

Your registrations include access to all the Online Sessions plus Bonus Courses through December 31st, 2021.

Virtual DiabetesEd Specialist Conference

Reserve your spot now for our

Virtual DiabetesEd Specialist Conference | April 15-17, 2021

Whether you are new to diabetes or a seasoned expert, you’ll benefit from this virtual conference with the latest research plus critical content that you can immediately apply to your clinical practice.

Entire Program Fee: $399
Dates: April 15-17, 2021
Live Webinar Schedule: All webinars start and end times are in Pacific Standard Time

DiabetesEd Virtual Conference Flyer 2021
Diabetes Ed Virtual 3-Day Schedule 2021

Team of Experts & Schedule

Coach Beverly Thomassian, RN, MPH, BC-ADM, CDCES

Author, Nurse, Educator, Clinician and Innovator, Beverly has specialized in diabetes management for over twenty years. As president and founder of Diabetes Educational Services, Beverly is dedicated to optimizing diabetes care and improving the lives of those with diabetes.


Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES

We are thrilled to welcome our newest speaker, Diana Isaacs, who will be joining our Virtual and Live Courses!

Dr. Isaacs was named 2020 AADE Diabetes Educator of the Year for her educational platform promoting the use of CGM for people with diabetes and other innovations.  Dr. Isaacs was awarded the Ohio Pharmacists Association Under 40 Award in 2019. Dr. Isaacs has served in leadership roles for several pharmacies and diabetes organizations. She has numerous diabetes publications and research projects with a focus on medications, CGM and diabetes technology.

As the CGM Program Coordinator and clinical pharmacist specialist in the Cleveland Clinic Diabetes Center, Dr. Isaacs brings a wealth of clinical knowledge combined with extensive research experience to this program.

Diabetes Meds and Insulin Toolkit – with Dr. Diana Isaacs | 4.0 CEs
April 15  10:30 am – 12:30 BREAK and 1:15 – 3:15 PST 

*Topics include:

  • Diabetes Medications, What Diabetes Specialists Need to Know
    • Update on the latest medication information
    • How to put ADA and AACE Algorithms into practice
    • Critical teaching points with a focus on safety
  • Insulin – The Ultimate Hormone Replacement Therapy
    • Latest update on available insulins
    • How to use ADA algorithm for insulin management
    • Teaching pointers for safe and effective insulin use

Technology Toolkit with CV Management Update – Dr. Diana Isaacs | 4.0 CEs – 
April 16 with 8:30—12:30 am  

  • Intensive Insulin Therapy— From Carbs to Correction to reach glucose targets
    • Formulas on determining insulin coverage for carbs and hyperglycemia
    • Using glucose results to evaluate effectiveness
  • Integrating Technology, Continuous Glucose Monitoring and Insulin Pumps into care.
    • Update on the latest technology, from meters to CGM with an emphasis on problem solving.
    • Delivering insulin, from pens to pumps
    • Understanding glucose reports and determining best action
  • CV Risk Management with a Pharmacology Focus
    • Apply the ADA guidelines to improve CV outcomes
    • Describe the preferred medication using a case study approach

Ashley LaBrier, MS, RD, CDCES

Ashley is an educator, dietitian, and the Diabetes Education Program Coordinator at the Salinas Valley Medical Clinic’s Diabetes & Endocrine Center. Her work with people living with diabetes focuses on the value of healthy nutrition and movement to improve well-being.

Ashley is passionate about providing person-centered education to empower those who live with diabetes. Having been diagnosed with type 1 diabetes herself nearly 20 years ago, she combines her professional knowledge with personal experience and understanding. 

April 17 with Ashley LaBrier, MS, RD, CDCES
8:30 am — 12:30 pm PST

  • Medical Nutrition Therapy Overview  
  • Meal Planning – How to Eat by the Numbers
  • Keeping Well Through Activity and Nutrition

*Dates and times subject to change. Course start and end time are for Pacific Standard Timezone.


DiabetesEd Virtual Conference Flyer 2021
Diabetes Ed Virtual 3-Day Schedule 2021

Bonus Courses – Course registration includes FREE enrollment into our Level 2 Standard of Care Course Series including:

  • Level 2 – Assessing and Promoting Well-Being: From Population Health to a Person-Centered Approach 1.5 CEs
  • Level 2 – Hospital and Hyperglycemia 1.5 CEs
  • Level 2 – Hyperglycemic Crisis, DKA and HHS Standards 1.0 CEs
  • Level 2 – Meds Management Update for Type 2 – 1.5 CEs
  • Level 2 – Pattern Management Gone Crazy 2.65 CEs
  • Level 2 – Setting up a Successful Diabetes Program 1.5 CEs
  • Level 2 – Women and Diabetes 1.5 CEs
  • Level 2 – From Tots to Teens – Diabetes Standards 1.5 CEs
  • Level 2 – From Tots to Teens – Diabetes Standards 1.5 CEs
  • Level 2 – Older Adults and Diabetes 1.5 CEs
  • Test Taking Toolkit
  • Mindfulness and Compassion in the Diabetes Encounter – 1.0 CE

Team of expert faculty includes:

  • Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES – Educator of the Year, 2020
  • Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM
  • Ashley LaBrier, MS, RD, CDCES, Diabetes Program Coordinator

In addition to informative lectures, we also use group activities and case studies to highlight the essential knowledge, skills, and strategies needed to succeed in diabetes education today! 

Prepare for CDCES or BC-ADM certification or earn hours for renewal.

Your registrations include access to all the Online Sessions plus Bonus Courses through December 31st, 2021.

This virtual program includes:

3 day live webinar courses from April 15th-17th (20 CEs) + enrollment in our Bonus Bundle (14.0+ CEs) from now through December 2021.

  • Live Q & A Session with the instructor after each webinar
  • Presentations by our team of experts
  • Handouts and Resources for each session
  • Post-test questions
  • A sense of community
  • If you can’t attend the live webinars, a recorded version will be posted later the same day for viewing.

View full Conference Schedule and Faculty.


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Treating DKA with Sub-Q Insulin?

What are the treatment options for people with type 1 diabetes with a COVID infection hospitalized for Diabetes KetoAcidosis (DKA)?

The typical treatment for DKA is fluids coupled with an IV insulin drip. Given the frequent monitoring and ICU bed required for treatment of DKA with an insulin drip, there has been a renewed interest in treating DKA with subcutaneous or sub-q insulin.

But after doing some research, I discovered an excellent 2004 paper co-authored by Dr. Guillermo Umpierrez et al. on using Sub-Q Insulin to Treat DKA. After completing a study comparing treatment of DKA using sub-q insulin vs. insulin drip, the author’s conclude that sub-Q insulin treatment is a safe and effective alternative treatment to IV insulin in the management of people with mild or moderate DKA.

With a little more digging, I found 2 more recent papers that suggest considering Sub-Q insulin treatment as an option for mild or moderate DKA.

It is important to note that sub-Q insulin treatment for DKA is NOT recommended for patients with arterial hypotension, severe and complicated DKA, or with HHS.

Treating DKA with Sub-Q insulin Steps

Insulins: Use either rapid acting lispro or aspart insulin.

1st Bolus: Starting dose is 0.1 or 0.2 or 0.3 units/kg of insulin (depending on initial blood glucose and clinical presentation)

Example: Pt weighs 100 kg, give 100kg x 0.1 – 0.2 – 0.3 units/kg of insulin = 10 or 20 or 30 units insulin sub-q bolus respectively.

Next Step – Sub-q insulin every 2 hours | Give 0.1 – 0.2 units of insulin /kg every 2 hours until blood glucose is less than 250.

Example: Pt weighs 100 kg, give 100kg x 0.1 – 0.2 units/kg of insulin = 10 or 20 units insulin sub-q bolus respectively every 2 hours.

Blood glucose less than 250 | Now give 1/2 the sub-q insulin dose every 2 hours. Calculate 0.05 to 0.1 units/kg every 2 hours until glucose at target and ketosis is resolved.

Example: Pt weighs 100 kg, give 100kg x 0.05 – 0.1 units/kg of insulin = 5 or 10 units insulin sub-q bolus respectively every 2 hours.

Using scheduled subcutaneous insulin allows for safe and effective treatment in the emergency room and step-down units without the need for ICU care. Umpierrez et al

Please see reference chart and articles below for more detailed information.

Fluids and Electrolytes

Of course, fluid and electrolyte status needs to be assessed before starting insulin.

If the K+ is less than 3.3, hold insulin and start with IV fluids (NS or LR) first with potassium replacement. Once the K is stable, start the insulin injection every 2 hours (see article and flow chart below).

Med Clin North Am. 2017 May; 101(3): 587–606.
doi: 10.1016/j.mcna.2016.12.011
Management of Hyperglycemic Crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state

Thank you for reading this article. Please share any feedback or your experiences using sub-q insulin for DKA. We always love to hear from you. You can email us at info@diabetesed.net

Reference Articles

Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. Saudi J Med Med Sci. 2020;8(3):165-173. doi:10.4103/sjmms.sjmms_478_19

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017;101(3):587-606. doi:10.1016/j.mcna.2016.12.011


Hyperglycemic Crises, DKA & HHS | 1.0 CEs

Join Coach Beverly to learn more about causes and treatment of hyperglycemic crisis. (opens in a new tab)”>Find out more here>>

This course is included in: Level 2 – Standards of Care. Purchase this course individually for $19 or the entire bundle and save 70%. 

This 60-minute course discusses common causes of hyperglycemia crises. Topics include hyperglycemia secondary to medications and insulin deprivation. The difference and similarities between Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome are also covered. Treatment strategies for all situations are included.

Topics include:

  • Common causes of hyperglycemic crises.
  • The difference and similarities between DKA and HHS and treatment strategies
  • Causes and treatment of hyperglycemic crises.

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.* 

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

COVID-19 & Diabetes Resource Page | Free Resource Friday

As health care professionals and Diabetes Specialists, how do we keep up to date with all the latest information on diabetes and COVID-19?

How do we prepare people with diabetes for the possibility of a COVID-19 infection and hospitalization?

As Diabetes Care Specialists, it is important to have easy access to the latest information on COVID-19 and diabetes.

To help, we have put together a list of free resources by category so you can easily access important and relevant information about COVID-19.

Plus, we have updated our Sick Days / COVID-19 and Diabetes Handout that we invite you to share with colleagues and people living with diabetes.

COVID-19, Sick days & Diabetes: Handout

Updated to reflect the latest CDC guidelines. Reviews sick day instruction for people with diabetes, plus COVID-19 specific information.

Included in COVID-19 Resource page:

  • FREE Webinar on COVID & Diabetes
  • Past Blog Bytes on COVID-19
  • Article Library
  • Handouts

Article Library Sections

  • Overview
  • Social Determinants of Health and Racial Disparities
  • COVID Pathophysiology
  • Diabetes and COVID Research and Treatments
  • Long Haulers Syndrome and Vaccine Information


Upcoming Webinar
Level 2 | Older Adults and Diabetes Standards | 1.5 CEs
Join us live on December 23rd at 11:30 am (PST)

We have updated this content based on the ADA 2021 Standards of Care.

We are living longer and more people are getting diabetes. The American Diabetes Association has updated the Older Adults Standards, with special attention to considering a reduction of medication and insulin therapy intensity. The older population has unique issues and special needs that require consideration as we provide diabetes self-management education. This online course highlights key areas of assessment, intervention, and advocacy for older clients living with diabetes.

Topics include:

  • Self-management considerations for older individuals
  • Strategies to prevent complications and maintain optimal quality of life
  • The role of the Diabetes Educator as an advocate

Join us live on December 23rd at 11:30 am (PST)

Can’t join us live?
Don’t worry, we will send you a link to the recorded version.

This course is included in: Level 2 – Standards of Care Intensive. Purchase this course individually for $29 or the entire bundle and save 70%.

Enroll in our entire Level 2 – Standards of Care Intensive to join us for the below for Live Webinar Updates. All courses air at 11:30 a.m. (PST)

  1. December 23, 2020 – Older Adults & Diabetes – 1.5 CEs
  2. December 29, 2020 – Assessing Coping Skills Standards – 1.5 CEs
  3. December 30, 2020 – Hyperglycemic Crisis Standards – 1.0 CEs
  4. February 2, 2021 – 2021 Standards of Care Update  – 2.0 CEs

All hours earned count toward your CDCES Accreditation Information


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!


Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Admission Glucose Level Predicts COVID Related Deaths

Blood glucose levels provide an immediate snapshot of a person’s state of inflammation, with or without diabetes.

According to recent research findings, admission glucose is also an excellent predictor of COVID-19 related deaths and severity of illness.

Researchers in Spain retrospectively evaluated over 11,000 patients positive with COVID on admission in 109 hospitals throughout Spain. They also evaluated admission blood glucose levels and their findings were startling.


People with COVID and glucose levels of 140 mg/dL or greater were twice as likely to die than those with normal glucose levels (41.4% vs. 15.7%).


The researchers were also able to stratify the risk of death based on admissions glucose levels.

For all 11, 000 patients admitted with COVID in this study, the mortality rate was 20%.

Mortality Risk Stratified by BG

For patients with admission glucose of 140 – 180, the mortality rate increased to 33%.

The mortality rate skyrocketed to 41% if admission glucose was 180 mg/dL or greater.

Key messages

  • Screen for hyperglycemia in all admissions.
  • Maintain optimal blood glucose levels in an outpatient setting.
  • Early treatment of hyperglycemia should be mandatory for patients hospitalized with COVID-19.
  • Admission hyperglycemia should be addressed in all patients regardless of prior history of diabetes.
  • Based on recent research, hospitalized patients with diabetes also have improved outcomes when immediately started on the DPP-IV Inhibitor, Sitagliptin (Januvia).

Read More Here Admission hyperglycemia as a predictor of mortality in patients hospitalized with COVID-19 regardless of diabetes status: data from the Spanish SEMI-COVID-19 Registry. November 2020

Annals of Medicine by Francisco Javier Carrasco-Sánchez, MD, PhD, and colleagues. Nov 23, 2020


COVID & Diabetes Update – FREE Webinar | Ready for Viewing!

COVID & Diabetes Update
Navigating a Crisis

Recorded & Ready for Viewing

Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM, has completely updated this critical presentation, to bring health care professionals up-to-date on the current state of COVID and its impact on diabetes care. She summarizes key information including critical teaching points and management strategies for people with diabetes who develop a COVID-19 infection.

Topics Include:

  1. Discuss the current state of diabetes in the United States.
  2. Describe the relationship between COVID and health care disparities 
  3. Explore the impact of COVID infection on those with pre-existing diabetes.
  4. Discuss treatment strategies for COVID and diabetes, including new vaccines.
  5. List critical teaching points for people with diabetes and COVID.

Join us to learn critical information about Diabetes and COVID Management

Instructor: Beverly Thomassian RN, MPH, CDCES, has been Board Certified in Advanced Diabetes Management for over 20 years. She is an Associate Clinical Professor at UCSF and Touro University and a nationally recognized diabetes expert.


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

AccreditationDiabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Rationale| COVID & Diabetes Treatment

Our November 17th Question of the week quizzed test takers on COVID-19 and diabetes. Less than half, 48% of respondents, chose the best answer, We thought that this was an important topic to discuss further, so we can pass on correct info to people living with diabetes.

Join us for FREE Covid & Diabetes Webinar. Click here to view>>

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: COVID cases are surging throughout the United States. Providing the best care for people with diabetes is especially important during this crisis. Which of the following statements regarding diabetes and COVID is most accurate?

Answer Choices:

  1. Avoid use of ACE inhibitors during illness, especially during the critical phase.
  2. Administration of sitagliptin (Januvia) during hospitalization may be associated with improved outcomes.
  3. Steroid use during acute illness should be avoided to prevent hypoglycemic or hyperglycemic crisis.
  4. Supine positioning during the acute phase is associated with improved oxygen saturation.

As shown above, the most common choice was option 2, the second most common answer was option 1, then option 4, and finally option 3.

Getting to the Best Answer

If you are thinking about taking the certification exam, this practice test question will set you up for success. Test writers anticipate possible answers based on the details in the question. They will wave those “juicy answers” right under your nose. Your job is to weed through the particulars, pluck out the most important elements and choose the BEST answer.

Answer 1 is incorrect. 20.04% chose this answer. “Avoid use of ACE inhibitors during illness, especially during the critical phase.” Since the corona virus enters the body via ACE2 receptors, some early recommendations included stopping ACE inhibitors in those with COVID-19. However, scientists quickly discovered that stopping ACE inhibitors did NOT improve outcomes and that ACE inhibitors should be continued.

Answer 2 is correct. 47.61% of you chose this answer. “Administration of sitagliptin (Januvia) during hospitalization may be associated with improved outcomes.” YES. New research demonstrates that people with diabetes and COVID-19 started sitagliptin (Januvia) on hospital admission, experience dramatic decreases mortality and improved outcomes.

See our Blog Post Sitagliptin Improves Outcomes here

Answer 3 is incorrect. About 12.87% of respondents chose this. “Steroid use during acute illness should be avoided to prevent hypoglycemic or hyperglycemic crisis.” It is true that steroids can contribute to hyperglycemia in people with diabetes. However, since steroids have been shown to be lifesaving for very ill people with COVID, with or without diabetes, research supports administering the steroid while managing resultant hyperglycemia with insulin therapy.

Finally, Answer 4 is incorrect. 19.49% chose this answer. “Supine positioning during the acute phase is associated with improved oxygen saturation.” Research has shown that “prone” positioning (laying on belly) can improve alveolar oxygenation and outcomes. More info here.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!


COVID & Diabetes Update – Navigating a Crisis

Purchase recording of our Live Webinar on December 2 | Earn 1.5 CE | $19

With the surge in new COVID cases, what is the essential information health care professionals and Diabetes Specialists need to navigate this overwhelming crisis?

What are the best practices to care for people with diabetes and COVID-19 in the outpatient and hospital setting?

Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM, has completely updated this critical presentation, to bring health care professionals up-to-date on the current state of COVID and its impact on diabetes care. She summarizes key information including critical teaching points and management strategies for people with diabetes who develop a COVID-19 infection.

Topics Include:

  1. Discuss the current state of diabetes in the United States.
  2. Describe the relationship between COVID and health care disparities 
  3. Explore the impact of COVID infection on those with pre-existing diabetes.
  4. Discuss treatment strategies for COVID and diabetes, including new vaccines.
  5. List critical teaching points for people with diabetes and COVID.

If you miss the live version, your registration guarantees access to the recorded version.

Join us to learn critical information about Diabetes and COVID Management

Instructor: Beverly Thomassian RN, MPH, CDCES, has been Board Certified in Advanced Diabetes Management for over 20 years. She is an Associate Clinical Professor at UCSF and Touro University and a nationally recognized diabetes expert.


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!


AccreditationDiabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Forest Bathing | Oxygen Cocktails can Boost Your Killer T Cells

The winter and holiday seasons can be stressful and wear us down, especially during the pandemic. We tend to spend more time indoors. To help out, we have some suggestions that will not only help with stress management but can also boost your immunity.

Walking outside in nature and drinking in an “oxygen cocktail” feels good, but does it benefit our immunity?

You might be familiar with the term “Forest bathing” or shinrin-yoku. In Japanese, Shinrin means “forest,” and yoku means “bath.”  Shinrin-yoku means bathing in a forest atmosphere or taking in the forest through our senses.

Research has demonstrated that trips to the forest can not only make us feel better by lowering muscle tension, boosting sleep, and reducing blood pressure. It turns out being in nature also enhances our immune systems by increasing the number and activity of our lympocytes and killer T cells.

Phytoncides are Natures Immune Boosters

When we walk among trees and plants, we breathe in airborne chemicals from plants called phytoncides.

Plants produce these chemicals to protect themselves from insects, bacterial and fungal infections. Phytoncides help plants fight disease.

When people breathe in these phytoncides, our bodies respond by increasing the number and activity of a type of white blood cell called natural killer cells or NK.

These cells kill tumor and virus-infected cells in our bodies. In one study, increased NK activity from a 3-day, 2-night forest bathing trip lasted for more than 30 days.

Boost your immune system and state of mind.

According to Dr. Qing Li, author of the book, Forest Bathing, the key to unlocking the power of the forest is in the five senses:

  • Let nature enter through your ears, eyes, nose, mouth, hands, and feet.
  • Listen to the birds singing and the breeze rustling in the leaves of the trees.
  • Look at the different greens of the trees and the sunlight filtering through the branches.
  • Smell the fragrance of the forest and breathe in the natural aromatherapy of phytoncides.
  • Taste the freshness of the air as you take deep breaths. Place your hands on the trunk of a tree.
  • Dip your fingers or toes in a stream. Lie on the ground. Drink in the flavor of the forest and release your sense of joy and calm.
  • This is your sixth sense, a state of mind. Now you have connected with nature. You have crossed the bridge to happiness.

To read more, click here.


Surviving the Holidays – 10 Steps to Success

The holiday season can also be stressful and throw us off our normal routine. This can compromise our sleep and our overall eating habits.

To help everyone feel their best during this holiday season, we have ten strategies for you and your patients. And even if you can’t do all ten, just pick one or a few that you feel you can commit to and succeed with most of the time.

We have created a 10 Steps to Survive the Holidays PDF – a handout that includes the info below to print and share with your friends, patients, and colleagues!

COVID & Diabetes Update – Navigating a Crisis

COVID & Diabetes Update
Navigating a Crisis

Recorded & Ready for Viewing

Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM, has completely updated this critical presentation, to bring health care professionals up-to-date on the current state of COVID and its impact on diabetes care. She summarizes key information including critical teaching points and management strategies for people with diabetes who develop a COVID-19 infection.

Topics Include:

  1. Discuss the current state of diabetes in the United States.
  2. Describe the relationship between COVID and health care disparities 
  3. Explore the impact of COVID infection on those with pre-existing diabetes.
  4. Discuss treatment strategies for COVID and diabetes, including new vaccines.
  5. List critical teaching points for people with diabetes and COVID.

Join us to learn critical information about Diabetes and COVID Management

Instructor: Beverly Thomassian RN, MPH, CDCES, has been Board Certified in Advanced Diabetes Management for over 20 years. She is an Associate Clinical Professor at UCSF and Touro University and a nationally recognized diabetes expert.


FREE Resource Catalog

See Full Free Resource Catalog


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

AccreditationDiabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Sitagliptin Improves COVID-19 Outcomes in Diabetes

The COVID-19 Pandemic is taking a toll on people with diabetes.

Although people with diabetes are not more likely than the general population to be infected by COVID-19, they have much higher mortality rates than people without diabetes once infected with the virus.

Hopeful news. A recent study demonstrated that starting sitagliptin (Januvia) on hospital admission dramatically decreases mortality and improves outcomes for those with diabetes and COVID-19.

The Corona Virus appears to have two portals of entry in humans.

  • Corona Virus can enter through the ACE2 receptors that are located throughout the body.
  • Coronavirus also appears to bind to DPP-4 cells in the respiratory tract.

In a recent study released in September in Diabetes Care, “Type 2 Diabetes and COVID-19: A Multicenter, Case-Control, Retrospective, Observational Study by Solerte et al”, the researchers demonstrated reduced mortality, improved clinical outcomes, and a greater number of hospital discharges for those started on sitagliptin on admission.

The COVID-19 virus seems to bind to the DPP-IV enzyme and the enzymatic activity of DPP4 causes overexpression of inflammatory cytokines, exaggerating the inflammatory response.

Since sitagliptin is a DPP-IV inhibitor, the researchers believe that the medication inhibited the virus’s ability to bind to DPP-IV. This had a net effect of decreasing the intense inflammatory response, often termed the “cytokine storm” associated with COVID-19 infections.

Treatment with sitagliptin on admission dramatically improved outcomes.

This Multicenter, Case-Control, Retrospective, Observational Study followed 338 consecutive patients with type 2 diabetes and COVID-19 admitted to Northern Italy hospitals.

Included in this study were 169 patients on sitagliptin and 169 on the standards of care. All patients had pneumonia and exhibited oxygen saturation <95% when breathing ambient air or when receiving oxygen support.

RESULTS: Treatment with sitagliptin at the time of hospitalization was associated with:

  • Reduced mortality (18% vs. 37% of deceased patients; hazard ratio 0.44 [95% CI 0.29–0.66]; P 5 0.0001) }
  • Improvement in clinical outcomes (60% vs. 38% of improved patients; P 5 0.0001) }
  • Greater number of hospital discharges (120 vs. 89 of discharged patients; P 5 0.0008) compared with patients receiving standard of care, respectively.

Sitagliptin contributed to a lowered risk and progression of acute respiratory complications for people with type 2 diabetes and COVID-19.

This research suggests that DPP-4 inhibitors can help decrease COVID-19-related immune overreaction in people with diabetes and dramatically improve outcomes.

Read article here >> Sitagliptin Treatment at the Time of Hospitalization was Associated with Reduced Mortality in Patients with Type 2 Diabetes and COVID-19: A Multicenter, Case-Control, Retrospective, Observational Study, Solerte et al. Diabetes Care 2020, Sept


Want to learn more about the most recent finding in Diabetes and COVID-19?

COVID & Diabetes Update
Navigating a Crisis

Recorded & Ready for Viewing

Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM, has completely updated this critical presentation, to bring health care professionals up-to-date on the current state of COVID and its impact on diabetes care. She summarizes key information including critical teaching points and management strategies for people with diabetes who develop a COVID-19 infection.

Topics Include:

  1. Discuss the current state of diabetes in the United States.
  2. Describe the relationship between COVID and health care disparities 
  3. Explore the impact of COVID infection on those with pre-existing diabetes.
  4. Discuss treatment strategies for COVID and diabetes, including new vaccines.
  5. List critical teaching points for people with diabetes and COVID.

Join us to learn critical information about Diabetes and COVID Management

Instructor: Beverly Thomassian RN, MPH, CDCES, has been Board Certified in Advanced Diabetes Management for over 20 years. She is an Associate Clinical Professor at UCSF and Touro University and a nationally recognized diabetes expert.


Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

AccreditationDiabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.