What is the recommended rate of glucose reduction in a patient presenting to the Emergency Room (ER) with hyperglycemia, not in Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State (HHS)?

From the Guidelines

For patients presenting to the ER with hyperglycemia who are not in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), blood glucose should be reduced gradually at a rate of approximately 50-75 mg/dL per hour. The initial management typically involves subcutaneous insulin rather than intravenous insulin, as recommended by the most recent guidelines 1.

Key Considerations

• For most non-emergent hyperglycemia, a reasonable approach is to administer a subcutaneous dose of rapid-acting insulin (such as lispro, aspart, or glulisine) at 0.1 units/kg or a fixed dose of 4-10 units, followed by reassessment in 2-4 hours.
• Concurrent evaluation for the underlying cause of hyperglycemia is essential, as emphasized in previous studies 1.
• Oral intake should be assessed, and if the patient can eat, consider initiating or adjusting their home insulin regimen.
• For patients with type 2 diabetes, oral medications may be restarted if appropriate, according to the latest management guidelines 1.

Monitoring and Adjustments

• Rapid correction of hyperglycemia should be avoided as it can lead to symptomatic hypoglycemia or rapid fluid shifts.
• The goal is to achieve a target blood glucose of 140-180 mg/dL in most hospitalized patients.
• Frequent monitoring (every 1-2 hours initially, then every 4-6 hours once stable) is important to assess response to treatment and prevent hypoglycemia, as highlighted in the study 1.

Insulin Regimen

• The use of basal insulin with or without correction doses, or a basal-bolus regimen, may be considered depending on the severity of hyperglycemia and the patient's insulin requirements, as outlined in the management guidelines 1.
• The dose of insulin should be adjusted based on the patient's response to treatment, with the goal of achieving a gradual reduction in blood glucose levels.

From the Research

Glucose Reduction in Hyperglycemia

• The recommended rate of glucose reduction in a patient presenting to the Emergency Room (ER) with hyperglycemia, not in Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State (HHS), is not explicitly stated in the provided studies.
• However, a study on insulin therapy in hospitalized patients suggests that a target glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and noncritically ill patients 2.
• Another study on the management of hyperglycemia and diabetes in the emergency department highlights the importance of optimizing hyperglycemia management in the ED to improve clinical outcomes, but does not provide a specific rate of glucose reduction 3.
• A study on the association of emergency department treatments for hyperglycemia with glucose reduction and emergency department length of stay found that 10 units of subcutaneous insulin and 1 liter of intravenous fluid were associated with 33 mg/dL and 27 mg/dL glucose reduction, respectively 4.

Hyperglycemia Management

• The management of hyperglycemia in the emergency department is crucial to prevent further complications and improve clinical outcomes 3, 5.
• Insulin therapy is the most appropriate method for controlling glycemia in hospital, but is associated with increased risk of hypoglycemia 2.
• Continuous intravenous insulin infusion is the best method for achieving glycemic targets in critically ill patients, while a basal-bolus insulin strategy is preferred for noncritically ill patients 2.