What is the initial management for a patient with hyperglycemia and no evidence of diabetic ketoacidosis (DKA), normal venous blood gas (VBG), and negative ketones?

From the Guidelines

The initial management for a patient with hyperglycemia and no evidence of diabetic ketoacidosis (DKA), normal venous blood gas (VBG), and negative ketones should start with basal insulin, typically initiated at 10 units or 0.1 to 0.2 units/kg of body weight, as recommended by the American Diabetes Association standards of medical care in diabetes 1. When managing such a patient, it's crucial to consider the severity of hyperglycemia and the presence of symptoms or catabolic features.

• The choice of basal insulin (neutral protamine Hagedorn, glargine, detemir, or degludec) is based on the patient's specific needs and the clinical context.
• Insulin therapy should be adjusted based on self-monitoring of blood glucose (SMBG) levels, with the goal of achieving target glycemic levels without causing hypoglycemia.
• The use of metformin, if not contraindicated, can be considered in conjunction with insulin therapy, especially in patients with type 2 diabetes, starting at a dose of 500mg twice daily.
• Regular follow-up is essential to monitor the patient's response to therapy and make adjustments as necessary to maintain optimal blood glucose control and prevent complications. The approach to managing hyperglycemia without DKA involves a careful balance of insulin therapy, oral medications when appropriate, and close monitoring to achieve glycemic control while minimizing the risk of hypoglycemia and other adverse effects, as outlined in the standards of care 1.

From the Research

Initial Management

• The initial management for a patient with hyperglycemia and no evidence of diabetic ketoacidosis (DKA), normal venous blood gas (VBG), and negative ketones is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the management of DKA and hyperglycemic hyperosmolar syndrome (HHS) is discussed in several studies, which may provide some guidance for patients with hyperglycemia without DKA or HHS.

Fluid Management

• A study on the initial fluid management of diabetic ketoacidosis in children found that excessive fluid therapy was common, and education of emergency physicians is needed to reduce fluid therapy and the risk of neurologic complications 4.
• Another study proposed a physiologic approach to treatment of DKA, incorporating the principles of rehydration of hypertonic states, and found that gradual replacement of the volume of deficit over 48 hours with special attention to changes in effective osmolality can minimize the risk of brain herniation during treatment 5.

Insulin Therapy

• Insulin therapy is the cornerstone of therapy for DKA, and fluid replacement is the cornerstone of therapy for HHS 3.
• A study on the management of decompensated diabetes found that the three-pronged approach to therapy for either DKA or HHS consists of fluid administration, intravenous insulin infusion, and electrolyte replacement 3.

Electrolyte Replacement

• Electrolyte replacement is an important part of the management of DKA and HHS, as patients with these conditions often have significant electrolyte imbalances 3, 6.
• A study on fluid and electrolyte disorders associated with DKA and HHS found that the nursing process should be used to correct the fluid and electrolyte imbalances and to prevent further complications in both DKA and HHS 6.