Management of Severe Hyperglycemia

Initial Management

The American Diabetes Association recommends initiating insulin therapy immediately for persistent hyperglycemia >180 mg/dL, with a target glucose range of 140-180 mg/dL, using a basal-bolus insulin regimen 1, 2
A basal-bolus insulin regimen, consisting of basal insulin (long-acting analog such as glargine or detemir) and prandial insulin (rapid-acting analog such as aspart, lispro, or glulisine), is preferred over sliding scale insulin alone for glycemic control 3
Continuous intravenous insulin infusion may be considered initially if glucose is severely elevated (>400 mg/dL) until stabilized, according to The Lancet Diabetes and Endocrinology 4
Blood glucose should be monitored every 4-6 hours if NPO or before meals if eating, as recommended by the American Diabetes Association 1

Point-of-care glucose monitoring should be performed before meals and at bedtime, with insulin doses adjusted daily based on glucose patterns, as recommended by the American Diabetes Association 1, 2
The American Diabetes Association recommends avoiding hypoglycemia (glucose <70 mg/dL), which requires immediate treatment and regimen review 5
HbA1c testing may be considered if not done within the past 3 months to assess chronic glycemic control, according to the American Diabetes Association 6

Serum sodium levels should be monitored at least daily until stabilized, with fluid therapy adjusted based on sodium trends and clinical status, as recommended by The Lancet Diabetes and Endocrinology 4, 5
Other electrolyte abnormalities, particularly potassium, should be monitored, as they can be affected by insulin therapy, according to The Lancet Diabetes and Endocrinology 4

The American Diabetes Association recommends transitioning to an appropriate outpatient diabetes regimen 1-2 days before discharge, with consideration of HbA1c levels and glucose control 7
Diabetes education should be provided regarding blood glucose monitoring, insulin administration techniques, recognition and management of hypoglycemia, and dietary recommendations, as recommended by the American Diabetes Association 7

The American Diabetes Association strongly discourages relying solely on sliding scale insulin (SSI) without basal insulin, as this approach is ineffective 2, 3
Overly aggressive glucose control (targets <140 mg/dL) should be avoided, as it may increase the risk of hypoglycemia, according to the American Diabetes Association 1
Fluid administration should be cautious in the setting of hyponatremia to prevent rapid changes in serum sodium, as recommended by the American Diabetes Association 5
Stress hyperglycemia (new-onset hyperglycemia during illness) requires different follow-up than established diabetes, according to the American Diabetes Association 7
Hyponatremia can complicate management and is associated with worse outcomes, according to the American Diabetes Association 5