From the Guidelines
Severe hyperglycemia without hyperosmolar hyperglycemic state (HHS) should be treated with insulin therapy as the primary intervention, using a basal-bolus regimen, as recommended by the most recent and highest quality study 1.
Treatment Approach
The treatment approach should prioritize insulin therapy, with the goal of gradually reducing blood glucose to a target range of 140-180 mg/dL in hospitalized patients, while avoiding rapid drops that could cause neurological complications.
- Start with subcutaneous insulin using a basal-bolus regimen, typically beginning with 0.5-0.7 units/kg/day total insulin, divided as 50% basal and 50% as rapid-acting insulin.
- For very high blood glucose levels (>350 mg/dL), consider starting with a small correction dose of rapid-acting insulin (0.1 units/kg) to initiate glucose lowering.
- Ensure adequate hydration with oral or IV fluids if needed, and monitor electrolytes, particularly potassium, as insulin therapy can cause hypokalemia.
- Check blood glucose every 4-6 hours initially, then adjust to pre-meal and bedtime testing once stabilized.
Underlying Causes
Identify and treat any underlying causes of hyperglycemia, such as:
- Infection
- Medication effects
- Stress ### Maintenance Regimen Once stabilized, transition to an appropriate maintenance regimen based on whether the patient has type 1 or type 2 diabetes, including consideration of oral agents for type 2 diabetes patients when appropriate, as suggested by 1 and supported by 2. The use of a DPP-4 inhibitor with or without a low basal insulin dose can achieve similar control to that achieved with a more complex insulin regimen in patients with mild hyperglycemia, as noted in 1. However, for patients with severe hyperglycemia, a more complex regimen, such as basal-bolus, is indicated, as recommended by 1 and 2.
From the Research
Treatment for Severe Hyperglycemia
- The treatment for severe hyperglycemia without Hyperosmolar Hyperglycemic Syndrome (HHS) can vary depending on the patient's specific condition and medical history 3, 4.
- For patients with type 2 diabetes, non-insulin medications may be effective in managing severe hyperglycemia, and in some cases, may be more effective than insulin therapy 3.
- In patients with acute coronary syndrome, treatment of hyperglycemia is recommended, and can include intravenous insulin with concomitant infusion of glucose solution under strict monitoring 4.
- Once the patient is no longer in intensive care, the treatment can be switched to a fixed insulin therapy regimen or oral antidiabetics in consultation with diabetologists 4.
- Good glycemic control is important for improving both prognosis and survival, especially during the rehabilitation phase 4.
Specific Treatment Approaches
- Intravenous insulin therapy can be used to treat hyperglycemia in the intensive care unit, but is not recommended once the patient is no longer in intensive care 4.
- Continuous glucose monitoring (CGM) devices can be used to monitor glucose levels in critically ill patients, and can help reduce the risk of iatrogenic hypoglycemia 5.
- Low-dose continuous intravenous insulin therapy can be as effective as high-dose therapy in treating severe diabetic ketoacidosis, and bicarbonate administration may be unnecessary 6.