Managing Severe Hyperglycemia

Initial Assessment and Treatment

For a patient with severe hyperglycemia (A1c of 13%), the American Diabetes Association recommends immediately initiating dual therapy with basal insulin (such as Lantus/glargine) and metformin, while using prandial insulin (such as Humalog/lispro) for meal coverage to rapidly correct this severe hyperglycemia 1
Before initiating treatment, it is essential to assess for ketosis/ketoacidosis by checking for symptoms, urine or serum ketones, and metabolic acidosis, as recommended by the American Diabetes Association 2, 3
The assessment should also include evaluating for hyperosmolar hyperglycemic state (HHS) if blood glucose is ≥600 mg/dL, with serum osmolality, mental status changes, and severe dehydration, according to the American Diabetes Association 2, 3, 4

The initial dose of basal insulin (Lantus/glargine) should be 0.5 units/kg/day administered once daily, typically at bedtime, as recommended by the American Diabetes Association 1
For a 70 kg patient, the initial dose would be approximately 35 units daily, according to the American Diabetes Association 2
The American Diabetes Association recommends titrating basal insulin every 2-3 days based on fasting blood glucose, targeting 80-130 mg/dL 1
Prandial insulin (Humalog/lispro) should be initiated with a basal-bolus regimen, with rapid-acting insulin before each main meal, as recommended by the American Diabetes Association 2, 5
The initial dose of prandial insulin can be approximately 4-6 units before each meal, or calculated as 50% of total daily insulin dose divided among three meals, according to the American Diabetes Association 4

Metformin should be started at 500 mg twice daily with meals if renal function is normal (eGFR >30 mL/min), as recommended by the American Diabetes Association 1
The dose of metformin can be titrated up to 1000 mg twice daily (2000 mg total daily dose) over 1-2 weeks to minimize gastrointestinal side effects, according to the American Diabetes Association 1
The American Diabetes Association recommends initiating metformin simultaneously with insulin for long-term management 2, 3

Blood glucose monitoring should include checking fasting glucose daily and pre-meal/2-hour post-meal glucose at least 3-4 times daily initially, as recommended by the American Diabetes Association 2, 3
A1c measurement should be performed every 3 months to assess glycemic control, according to the American Diabetes Association 2, 3
The American Diabetes Association recommends aiming for A1c <7.0% (53 mmol/mol) for most patients on this regimen, with more stringent targets of <6.5% if achieved without significant hypoglycemia 2, 5

Once glycemic targets are consistently achieved, insulin can be reduced by 10-30% every few days while continuing metformin, as recommended by the American Diabetes Association 2, 3
The American Diabetes Association suggests monitoring glucose closely during tapering to ensure control is maintained 1

With this aggressive basal-bolus regimen plus metformin, expect A1c reduction of approximately 3-4% over 3-6 months, according to the American Diabetes Association 1
Most patients should achieve A1c <7% within 6 months if adherent, as recommended by the American Diabetes Association 2, 5