What is the management of hyperglycemia?

Management of Hyperglycemia

The management of hyperglycemia requires a structured approach based on the clinical setting, with insulin therapy being the standard of care for critically ill patients and a combination of lifestyle modifications and pharmacological interventions for non-critically ill patients. 1, 2

Acute Hyperglycemia in Hospital Settings

Critical Illness

• Intravenous insulin is the treatment of choice for hyperglycemia in critically ill patients 1, 3
• Target blood glucose range: 140-180 mg/dL (5.6-10.0 mmol/L) 1
• Stricter glycemic targets (<110 mg/dL) are not advised as they don't improve outcomes and increase hypoglycemia risk 1
• Monitor blood glucose every 2-4 hours while NPO (nothing by mouth) 1

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)

• Management goals include:
  • Restoration of circulatory volume and tissue perfusion
  • Resolution of hyperglycemia
  • Correction of electrolyte imbalance and acidosis
  • Treatment of underlying cause (sepsis, myocardial infarction, stroke) 1
• Continuous IV insulin is standard of care for critically ill and mentally obtunded patients 1
• Successful transition from IV to subcutaneous insulin requires administration of basal insulin 2-4 hours before stopping IV insulin 1
• Bicarbonate use is generally not recommended in DKA treatment 1

Non-Critical Illness

• Basal-bolus insulin regimens are preferred for patients with good nutritional intake 4
• Components include:
  • Basal insulin (long-acting)
  • Prandial insulin (meal-time)
  • Correction insulin (for hyperglycemia) 4
• For patients with poor or no oral intake, a single dose of long-acting insulin plus correction insulin is preferred 4

Perioperative Management

1. Target glucose range: 80-180 mg/dL (4.4-10.0 mmol/L) within 4 hours of surgery 1
2. Hold metformin on the day of surgery 1
3. Discontinue SGLT2 inhibitors 3-4 days before surgery 1
4. Hold oral glucose-lowering agents on the morning of surgery 1
5. For NPH insulin, give half the dose; for long-acting analogs or insulin pump basal insulin, give 75-80% of usual dose 1
6. Monitor blood glucose every 2-4 hours while NPO 1

Outpatient Management of Hyperglycemia

Initial Pharmacological Approach

1. Metformin remains the preferred first-line agent due to its efficacy, safety profile, beneficial effects on A1c and weight, and low cost 2

   • Starting dose: 500 mg daily, increasing to 1000 mg twice daily as tolerated
   • Monitor for vitamin B12 deficiency with long-term use

2. GLP-1 receptor agonists provide significant weight loss benefits, potent A1c-lowering effects, and cardiovascular benefits in high-risk patients 2

3. Insulin therapy considerations:

   • Basal insulin (long-acting): Provides relatively uniform insulin coverage throughout the day and night 1
   • Options include intermediate-acting (NPH) or long-acting (insulin glargine or insulin detemir) 1
   • Long-acting analogs are associated with less overnight hypoglycemia but are more expensive 1
   • Prandial insulin (rapid-acting): For patients with progressive diminution in insulin secretory capacity 1
   • Options include insulin lispro, insulin aspart, or insulin glulisine 1

4. SGLT2 inhibitors (e.g., empagliflozin) have cardiovascular benefits but require careful monitoring for ketoacidosis and must be discontinued 3-4 days before surgery 1, 5

5. Sulfonylureas (e.g., glipizide) are effective but carry hypoglycemia risk, especially in elderly, debilitated, or malnourished patients 6

Lifestyle Interventions

• Implement intensive lifestyle interventions targeting 5-10% weight loss 2
• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week, plus resistance training twice weekly 2
• Recommend individualized medical nutrition therapy, focusing on nutrient-dense foods and reduced consumption of calorie-dense, nutrient-poor foods 2

Monitoring and Follow-up

• Short-term monitoring (2-4 weeks): Monitor fasting and postprandial glucose levels, assess for medication side effects, and adjust insulin dose if initiated 2
• Medium-term follow-up (3 months): Reassess A1c, evaluate weight changes, and consider medication adjustments if A1c reduction is inadequate 2
• Educate patients on self-monitoring of blood glucose and hypoglycemia management 2, 7

Complications and Special Considerations

Hypoglycemia

Common causes include:

• Missing or delaying meals
• Taking too much insulin
• Exercising more than usual
• Infection or illness
• Changes in insulin requirements due to organ dysfunction 7

Symptoms range from mild (sweating, drowsiness, dizziness) to severe (disorientation, seizures, unconsciousness) 7

Management:

• Mild to moderate: Consume sugar-containing foods or drinks
• Severe: Requires glucagon injection or IV glucose 7

Hyperglycemia and DKA

Causes include:

• Omitting insulin or taking less than prescribed
• Eating significantly more than planned
• Developing fever, infection, or significant stress 7

DKA symptoms develop gradually:

• Drowsiness, flushed face, thirst, loss of appetite, fruity breath odor
• Later: nausea, vomiting, stomach pain, dehydration 7

Transition from Hospital to Outpatient Care

• Develop a structured discharge plan tailored to the individual 1
• Begin discharge planning at admission and update as needs change 1
• Include diabetes education, medication reconciliation, and scheduled follow-up visits 1
• Consider the patient's capabilities and preferences when designing the discharge plan 1

Common Pitfalls to Avoid

1. Relying solely on sliding-scale insulin without basal insulin coverage 8
2. Failing to adjust insulin doses based on nutritional intake changes 4
3. Not accounting for medication interactions that can potentiate hypoglycemia (e.g., beta-blockers, salicylates) 6
4. Overlooking the need for transition planning from IV to subcutaneous insulin 1
5. Not considering renal function when dosing metformin and other medications 2
6. Inadequate monitoring for hypoglycemia, especially in elderly patients 6