Management of Severe Hyperglycemia

Initial Management

For severe hyperglycemia (blood glucose ≥300 mg/dL or 16.7 mmol/L), insulin therapy should be initiated promptly, according to the American Diabetes Association, as part of an aggressive treatment approach to reduce hyperglycemia and prevent complications 1
Assess for symptoms of hyperglycemic crisis (polyuria, polydipsia, nausea, vomiting, abdominal pain, altered mental status) in patients with severe hyperglycemia 3
Check for signs of dehydration, electrolyte abnormalities, and acidosis in patients with severe hyperglycemia, as recommended by the European Association for the Study of Diabetes 2
Consider checking venous pH, electrolytes, and anion gap if diabetic ketoacidosis (DKA) is suspected in patients with severe hyperglycemia 3

Initial Novolog (insulin aspart) dose for severe hyperglycemia: 0.1 units/kg or approximately 7-10 units subcutaneously, as recommended by the American Association of Clinical Endocrinologists 4, 2
For insulin-naive patients with severe hyperglycemia, start with 0.3-0.5 units/kg total daily insulin dose, with half as basal insulin and half as prandial insulin, according to the International Diabetes Federation 4
For patients already on insulin with severe hyperglycemia, consider using 10-20% of total daily dose or 0.1 units/kg as correction dose, as recommended by the American Diabetes Association 1

After initial dose, implement a basal-bolus insulin regimen with basal insulin (glargine or detemir) once or twice daily and prandial insulin (Novolog) before meals for patients with severe hyperglycemia, as recommended by the European Association for the Study of Diabetes 4, 5, 1, 5
Target blood glucose range for most non-critically ill patients with severe hyperglycemia: 140-180 mg/dL, according to the American Association of Clinical Endocrinologists 2, 6, 7
Pre-meal targets should generally be <140 mg/dL for patients with severe hyperglycemia, as recommended by the International Diabetes Federation 7
Avoid rapid correction that might lead to hypoglycemia in patients with severe hyperglycemia, as recommended by the American Diabetes Association 2

Monitor blood glucose every 2-4 hours until stable in patients with severe hyperglycemia, as recommended by the European Association for the Study of Diabetes 2
Assess for hypoglycemia (blood glucose <70 mg/dL) in patients with severe hyperglycemia, according to the American Association of Clinical Endocrinologists 7
If blood glucose remains >180 mg/dL after initial dose, consider additional correction dose for patients with severe hyperglycemia, as recommended by the American Diabetes Association 1
Adjust insulin doses based on response: increase dose by 1-2 units or 10-15% if target not achieved, and decrease dose by 10-20% if hypoglycemia occurs in patients with severe hyperglycemia, according to the International Diabetes Federation 1

Evaluate hydration status and provide IV fluids if needed for patients with severe hyperglycemia, as recommended by the American Association of Clinical Endocrinologists 3
Monitor for electrolyte abnormalities, particularly potassium, in patients with severe hyperglycemia, according to the European Association for the Study of Diabetes 2, 3
Consider underlying causes of severe hyperglycemia (infection, medication non-adherence, new-onset diabetes) and address them accordingly, as recommended by the American Diabetes Association 7
For patients with type 1 diabetes and severe hyperglycemia, always maintain some insulin to prevent ketosis, according to the International Diabetes Federation 5
If blood glucose doesn't improve with subcutaneous insulin, consider IV insulin infusion for patients with severe hyperglycemia, as recommended by the European Association for the Study of Diabetes 2