How to manage a patient with severe hyperglycemia?

From the Guidelines

Management of severe hyperglycemia requires prompt intervention with insulin therapy, fluid replacement, and electrolyte correction, as recommended by the most recent guidelines 1. For a patient with a blood glucose level of 600 mg/dL, initiating IV regular insulin as a continuous infusion at 0.1 units/kg/hour after an initial bolus of 0.1 units/kg is crucial. Simultaneously, administering isotonic fluids (normal saline) at 15-20 mL/kg in the first hour, then adjusting to 250-500 mL/hour based on hydration status, is essential to address dehydration. Key considerations include:

• Monitoring blood glucose hourly and adjusting insulin rates to achieve a decrease of 50-75 mg/dL per hour.
• Potassium replacement when levels fall below 5.2 mEq/L; adding 20-40 mEq potassium to each liter of IV fluid when serum potassium is <4.0 mEq/L.
• Transitioning to D5W or D5 1/2NS while continuing insulin once blood glucose reaches 200 mg/dL to prevent hypoglycemia.
• For diabetic ketoacidosis, monitoring serum bicarbonate and anion gap until acidosis resolves.
• After stabilization, transitioning to subcutaneous insulin with overlapping coverage (starting subcutaneous insulin 1-2 hours before stopping IV insulin). Long-term management includes basal-bolus insulin therapy (e.g., glargine/detemir plus rapid-acting insulin) or oral agents for type 2 diabetes if appropriate, as supported by recent guidelines 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency)

To manage a patient with severe hyperglycemia, it is essential to follow these steps:

• Monitor blood glucose levels closely to assess the severity of hyperglycemia.
• Adjust insulin dosage as prescribed by the doctor to control blood glucose levels.
• Stay hydrated by drinking plenty of water to prevent dehydration.
• Follow a meal plan that is consistent with the patient's dietary needs and insulin regimen.
• Seek medical attention immediately if symptoms of diabetic ketoacidosis (DKA) occur, such as fruity odor on the breath, heavy breathing, and rapid pulse. 2

From the Research

Managing Severe Hyperglycemia

To manage a patient with severe hyperglycemia, such as one with a glucose level of 600 mg, several strategies can be employed:

• Glucagon-like peptide-1 (GLP-1) receptor agonists: These are established glucose-lowering drugs used in the management of type 2 diabetes, as discussed in 3. They have been shown to be efficient in reducing both glycated hemoglobin and body weight.
• Insulin therapy: Insulin is a crucial component of managing hyperglycemia, especially in cases of severe hyperglycemia. However, it is associated with an increased risk of hypoglycemia, as noted in 4.
• Patient education and involvement: Patient involvement is critical to intensive glycemic control and should involve frequent self-monitoring of blood glucose, adherence to treatment regimens, and knowledge of the interrelationship among physical activity, diet, and insulin, as highlighted in 4.

Treatment Options

Several treatment options are available for managing hyperglycemia:

• GLP-1 receptor agonists: Five GLP-1 receptor agonists are available, including exenatide, liraglutide, albiglutide, dulaglutide, and lixisenatide, as discussed in 5. The choice of a specific GLP-1 receptor agonist depends on patient preferences, potential adverse effects, and cost.
• Incretin-based therapies: Incretin-based therapies, including GLP-1 receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors, are attractive options for the treatment of type 2 diabetes, as they have glucose-lowering effects without the adverse effects of hypoglycemia and weight gain, as noted in 5.
• Insulin analogs: Modern pharmaceutical options, such as novel basal insulins and ultra-rapid-acting insulin analogs, have a safer profile in terms of hypoglycemia, as discussed in 6.

Preventing Hypoglycemia

To prevent hypoglycemia, several strategies can be employed:

• Continuous glucose monitoring: Continuous glucose monitoring and sensor-augmented insulin pump therapy with low glucose suspend technology can prevent hypoglycemia, as noted in 6.
• Education and support: Ongoing education and support for patients are crucial to help them become co-managers of their disease and reduce the risk of hypoglycemia, as highlighted in 6.
• GLP-1 receptor agonist treatment: GLP-1 receptor agonist treatment, such as exenatide, can prevent glucocorticoid-induced glucose intolerance and islet-cell dysfunction, as discussed in 7.