From the Guidelines
Treatment for a glucose level greater than 500 mg/dL requires immediate medical attention, typically with insulin therapy, as recommended by the most recent guidelines 1.
Key Considerations
- For hospitalized patients, an insulin drip starting at 0.1 units/kg/hour is recommended, with hourly glucose monitoring and adjustment of the infusion rate to achieve a gradual reduction of 50-100 mg/dL per hour.
- For outpatients who are not in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), rapid-acting insulin like lispro, aspart, or glulisine can be given at 0.1-0.2 units/kg subcutaneously, with repeat doses every 2-4 hours until glucose falls below 300 mg/dL.
Additional Recommendations
- Fluid replacement with normal saline is crucial, typically starting with 1 liter over the first hour, then adjusted based on hydration status.
- Potassium levels must be monitored as insulin therapy can cause hypokalemia.
- The underlying cause of severe hyperglycemia must be identified and addressed, whether it's medication non-compliance, infection, stress, or new-onset diabetes.
- Patients require close follow-up with adjustment of their maintenance diabetes regimen, which may include basal insulin (like glargine or detemir) plus mealtime insulin or oral medications depending on their specific condition, as suggested by recent studies 1.
Important Notes
- Clinical judgment combined with ongoing assessment of clinical status, including changes in the trajectory of glucose measures, illness severity, nutritional status, or concomitant medications that might affect glucose levels, should be incorporated into the day-to-day decisions regarding insulin dosing 1.
- Glycemic levels above 250 mg/dL may be acceptable in patients with severe comorbidities and in inpatient care settings where frequent glucose monitoring or close nursing supervision is not feasible, but levels above 500 mg/dL require immediate attention 1.
From the Research
Treatment for Glucose Greater Than 500
- The treatment for glucose greater than 500 is typically focused on managing hyperglycemic crisis, which can be life-threatening if not addressed promptly 2.
- Hyperglycemic crisis can be caused by uncontrolled diabetes mellitus and may result in significant morbidity or death 2.
- The management of hyperglycemic crisis typically requires critical care and hospitalization, and involves addressing hypovolemia, acidemia, hyperglycemia, electrolyte abnormalities, and precipitating causes 2.
- Insulin administration is often used to manage hyperglycemia, but it can also cause a reduction in serum potassium, magnesium, and phosphorus concentration, along with reduced renal magnesium excretion 3, 4.
- Other antidiabetic drugs, such as metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors, can also have effects on electrolyte levels and acid-base balance, and should be chosen carefully based on the patient's specific risk factors 3, 4.
- In the emergency department, hyperglycemia is often under-recognized and under-treated, and patients with elevated blood glucose levels may be discharged without being informed of their condition or referred for follow-up 5, 6.
- Optimal management of hyperglycemia in the emergency department, including proper follow-up and referral, can improve clinical outcomes and prevent readmission 6.
Key Considerations
- Hyperglycemic crisis requires prompt and aggressive treatment to prevent morbidity and mortality 2.
- The choice of antidiabetic drug should be based on the patient's specific risk factors for acid-base and electrolyte abnormalities 3, 4.
- Patients with elevated blood glucose levels should be informed of their condition and referred for follow-up to prevent progression to diabetes and improve clinical outcomes 5, 6.