Management of Severe Hyperglycemia

Initial Assessment and Management

The American Diabetes Association recommends evaluating for signs of hyperglycemic crisis, such as polyuria, polydipsia, nausea, vomiting, abdominal pain, and altered mental status, in patients with severe hyperglycemia, as indicated by a blood glucose level of 798 mg/dL 1
The American Diabetes Association suggests checking for dehydration status, which is likely significant given the hyponatremia and elevated anion gap, in patients with severe hyperglycemia 1
The American Association of Clinical Endocrinologists recommends initiating intravenous fluid therapy with 0.9% sodium chloride to address hyponatremia and dehydration in patients with severe hyperglycemia 2
The American Diabetes Association recommends starting intravenous insulin therapy rather than continuing subcutaneous insulin in patients with severe hyperglycemia, as the severity of hyperglycemia warrants more aggressive management 3

The American Association of Clinical Endocrinologists suggests implementing intravenous insulin infusion following a nurse-driven protocol with variable rate based on glucose values in patients with severe hyperglycemia 2
The American Diabetes Association recommends targeting a blood glucose range of 140-180 mg/dL for non-critically ill patients with severe hyperglycemia 1
The American Association of Clinical Endocrinologists recommends monitoring blood glucose every 1-2 hours initially until stable, then every 4-6 hours in patients with severe hyperglycemia 1
The American Diabetes Association suggests converting to subcutaneous insulin at 60-80% of the daily infusion dose when transitioning from IV insulin in patients with severe hyperglycemia 3

The American Diabetes Association recommends implementing a basal-bolus insulin regimen with basal insulin (glargine or detemir) once or twice daily and prandial insulin (lispro) before meals in patients with severe hyperglycemia 5
The American Association of Clinical Endocrinologists suggests increasing the total daily dose to 0.3-0.5 units/kg/day given the severe hyperglycemia 1
The American Diabetes Association recommends avoiding sole use of sliding scale insulin as it is strongly discouraged for inpatient management in patients with severe hyperglycemia 4

The American Diabetes Association recommends considering simplifying the insulin regimen if complexity is contributing to poor compliance in patients with severe hyperglycemia 6
The American Association of Clinical Endocrinologists suggests administering insulin after meals to ensure the dose is appropriate for the amount of carbohydrate consumed in patients with irregular meal consumption 6

The American Diabetes Association recommends monitoring for hypoglycemia (blood glucose <70 mg/dL) which is a risk during aggressive insulin therapy in patients with severe hyperglycemia 3
The American Association of Clinical Endocrinologists suggests scheduling follow-up within 1-4 weeks after discharge in patients with severe hyperglycemia 7
The American Diabetes Association recommends considering referral to diabetes education and endocrinology for ongoing management in patients with severe hyperglycemia 7

The American Diabetes Association recommends evaluating for underlying causes of severe hyperglycemia, such as infection or medication non-adherence, in patients with severe hyperglycemia 1
The American Association of Clinical Endocrinologists suggests addressing any social determinants of health that may be affecting medication adherence and diabetes self-management in patients with severe hyperglycemia 6