National Skin Centre1
Glucocorticoids remains the mainstay of treatment for bullous pemphigoid (BP). The extent of hyperglycemic complications in BP remains unknown. We aim to determine the incidence, and identify risk factors for hyperglycemic complications following diagnosis of BP.
A retrospective study of 166 bullous pemphigoid patients at 2 academic medical centres.
Hyperglycemic complications occurred in 39% patients, where 11% developed new onset diabetes mellitus (DM), and 4% developed hyperglycemic crisis. Twenty-four percent required hospital admissions for management of hyperglycemia. New onset DM was diagnosed exclusively in patients who received systemic glucocorticoids. Significant risk factors for developing hyperglycemia include existing DM (OR 24.3, CI 10.6-55.7), chronic renal failure (OR 3.5, CI 1.5-8.2), hypertension (OR 3.3, CI 1.5-7.5), obesity (OR 2.8, CI 1.1-7.5) and hyperlipidemia (OR 2.1, CI 1.1-4.2). One-year mortality was higher in patients with hyperglycemic complications (29%vs14%; OR 2.6, CI 1.2-5.6).
Glucocorticoids result mainly in postprandial hyperglycemia. Routine fasting glucose might lead to missed hyperglycemic events or DM. HbA1c which measures control over last 2-3 months is inaccurate during initial weeks of glucocorticoids treatment where the risk of DM appears to be the highest. Patients should be advised to measure blood glucose post-prandial, in the afternoon or evening instead, with goal of post-prandial glucose <10mmol/L. Management challenges include the ideal anti-diabetic agent, with insulin being the current agent of choice. There is also risk of hypoglycaemia on tapering of glucocorticoids as disease control improves.
Dermatologists need to be aware of the multi-morbidities and the attending interactions and complications, in treating BP patients.