Management of Non-Acidotic Hyperglycemia in the Emergency Room

Initial Assessment and Treatment

The American Diabetes Association recommends initiating insulin therapy when glucose levels are persistently ≥180 mg/dL, with a target glucose range of 140-180 mg/dL for most patients 1, 2
Immediately check blood glucose levels to confirm hyperglycemia (>140 mg/dL) 3
Assess for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) through laboratory tests including electrolytes, anion gap, and ketones 3
Identify and address any precipitating factors such as infection, myocardial infarction, or stroke 3

For critically ill patients, use intravenous insulin infusion with a starting threshold of no higher than 180 mg/dL, and maintain glucose levels between 140-180 mg/dL once IV insulin is started 1, 4
Use validated written or computerized protocols for IV insulin administration that allow for predefined adjustments in infusion rate 5
Consider lower glucose targets (120-140 mg/dL) for select patients such as cardiac surgery patients if achievable without significant hypoglycemia 1, 3
Avoid targets <110 mg/dL due to increased risk of hypoglycemia 1
For non-critically ill patients, use a basal-bolus insulin regimen with basal, nutritional, and correction components, and target premeal glucose levels <140 mg/dL and random blood glucose <180 mg/dL 1, 4, 5
Strongly avoid using sliding-scale insulin as the sole method of treatment 4, 5

When discontinuing IV insulin therapy, start subcutaneous insulin 1-2 hours before stopping the IV infusion, and convert to basal insulin at 60-80% of the daily IV infusion dose 5
For calculating subcutaneous insulin dose from IV insulin, use 1/2 of the total amount of insulin infused in 24 hours as the dose of slow-acting insulin, and divide the other 1/2 by 3 to determine the dose of ultra-rapid analogue insulin per meal 6, 7

For pre-prandial glucose ≥16.5 mmol/L (300 mg/dL) without ketosis, give 6 IU ultra-rapid analogue insulin subcutaneously and recheck glucose 3 hours later 6, 7
For pre-prandial glucose ≥16.5 mmol/L with ketosis, consider transfer to ICU for IV insulin therapy if ketonemia ≥1.5 mmol/L 6, 7
For stress hyperglycemia, insulin can be stopped progressively as blood glucose normalizes 7, 8
Reassess insulin regimen if blood glucose falls below 100 mg/dL to avoid hypoglycemia 1, 4
Modify regimen when blood glucose values are <70 mg/dL unless easily explained by factors such as missed meals 1, 4

Avoid sole use of sliding-scale insulin as it is strongly discouraged and associated with poor outcomes 4, 5
Prevent hypoglycemia by frequent monitoring and appropriate adjustment of insulin doses 4
Be aware that overaggressive glucose lowering increases risk of hypoglycemia and associated mortality 2
Ensure overlap when transitioning from IV to subcutaneous insulin to prevent rebound hyperglycemia 3, 5