Hyperglycemia Management in Diabetes

Initial Assessment and Treatment Strategy

The American Diabetes Association recommends starting with metformin as first-line therapy for type 2 diabetes unless contraindicated, and initiating it at or soon after diagnosis alongside lifestyle modifications 1, 2
Metformin is the optimal first-line drug for type 2 diabetes, offering the best cost-effectiveness and safety profile 1, 2
For mild-to-moderate hyperglycemia, start metformin with lifestyle changes, and allow 3-6 months for lifestyle changes in highly motivated patients with HbA1c <7.5% before adding medications 1, 2
For severe hyperglycemia, start combination therapy immediately—either two oral agents or basal insulin plus metformin 1, 3

The American Diabetes Association recommends starting with 10 units of basal insulin once daily, or 0.1-0.2 units/kg body weight, and titrating aggressively to achieve target fasting glucose levels 1, 7
Target fasting glucose levels are 80-130 mg/dL, and basal insulin should not be escalated beyond 0.5 units/kg/day without adding prandial coverage 7, 5, 6

Scheduled basal-bolus insulin regimens are superior to sliding scale insulin alone for non-critically ill hospitalized patients 4, 7
Start with 0.3-0.5 units/kg/day total daily dose, half basal and half bolus, for moderate hyperglycemia, and use lower doses for high-risk patients 4, 6

Never delay insulin initiation in patients not achieving goals with oral medications, as this prolongs hyperglycemia exposure and increases complication risk 1, 3, 6
Never use sliding scale insulin as monotherapy, as it treats hyperglycemia reactively rather than preventing it, leading to dangerous glucose fluctuations 7, 6
Never discontinue metformin when starting insulin, unless contraindicated, as the combination provides superior control with less weight gain 1, 3, 4

Implement a hypoglycemia protocol at every institution, and treat blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate 7, 6
Reduce insulin dose by 10-20% immediately when hypoglycemia occurs, and review and modify regimens to prevent recurrence 7, 5, 6

Daily fasting blood glucose monitoring is recommended during insulin titration, and HbA1c should be checked every 3 months during intensive management 5, 6, 1