Management of Severe Hyperglycemia
Initial Assessment and Management
- For a blood glucose of 515 mg/dL, immediate treatment with intravenous insulin is recommended to rapidly correct hyperglycemia and prevent metabolic decompensation, according to the American Diabetes Association 1, 2
- Evaluate for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), including mental status changes, dehydration, fruity breath odor, abdominal pain, nausea/vomiting, and ketones in urine or blood, as recommended by the American Diabetes Association 2
- Obtain laboratory tests including complete metabolic panel, serum ketones, arterial blood gas (if DKA suspected), and urinalysis, as suggested by the American Diabetes Association 2
Treatment Algorithm
- Initiate continuous intravenous insulin infusion for critically ill patients, with a target glucose range of 140-180 mg/dL for most patients, as recommended by the American Diabetes Association 1, 3
- Provide adequate fluid resuscitation to restore circulatory volume and tissue perfusion, and correct electrolyte imbalances, particularly potassium, according to the American Diabetes Association 2
- For non-critically ill patients with DKA or HHS, intravenous insulin is the standard of care, and successful transition from IV to subcutaneous insulin requires administration of basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia, as recommended by the American Diabetes Association 2, 4
- For non-critically ill patients without DKA/HHS, insulin therapy should be initiated for persistent hyperglycemia ≥180 mg/dL, and for markedly elevated glucose (≥250 mg/dL) with symptoms, start basal insulin while initiating metformin, as suggested by the American Diabetes Association 1, 5, 6
Special Considerations
- Avoid bicarbonate use in DKA as studies show no benefit in resolution of acidosis, according to the American Diabetes Association 2
Transition of Care
- Develop a structured discharge plan tailored to the individual patient, and transition from IV to subcutaneous insulin requires overlap of 2-4 hours to prevent rebound hyperglycemia, as recommended by the American Diabetes Association 2, 4
- For patients initially treated with insulin and metformin who meet glucose targets, insulin can be tapered over 2-6 weeks by decreasing the dose 10-30% every few days, as suggested by the American Diabetes Association 6
Monitoring and Follow-up
- Schedule follow-up within 1-2 weeks to reassess glycemic control and adjust therapy as needed, according to the American Diabetes Association 2