What is the first line of management for hyperglycaemia?

First-Line Management of Hyperglycemia

The first-line management for hyperglycemia in type 2 diabetes is metformin, unless contraindicated, combined with lifestyle modifications including diet and exercise. 1

Initial Assessment and Management Algorithm

For Newly Diagnosed Hyperglycemia:

• Assess severity of hyperglycemia to guide initial treatment approach 1:
  • If HbA1c <7.5% and patient is highly motivated: Consider lifestyle intervention alone for 3-6 months before pharmacotherapy 1
  • If HbA1c is moderately elevated or lifestyle changes unlikely to be successful: Start metformin immediately 1
  • If HbA1c ≥9.0%: Consider combination therapy with two non-insulin agents or insulin 1
  • If HbA1c ≥10.0% or glucose >300-350 mg/dL with symptoms: Strongly consider insulin therapy from outset 1, 2
  • If catabolic features or ketonuria present: Insulin therapy is mandatory 1

Lifestyle Modifications (Foundation of Treatment):

• Dietary recommendations 1:

  • Personalized nutrition plan with emphasis on foods high in fiber (vegetables, fruits, whole grains, legumes)
  • Reduced intake of high-energy foods and saturated fats
  • Consistent carbohydrate intake to help manage postprandial glucose excursions

• Physical activity targets 1, 3:

  • At least 150 minutes per week of moderate-intensity aerobic activity
  • Include resistance and flexibility training
  • Reduce sedentary time throughout the day
  • For older individuals or those with mobility issues, any increase in activity is beneficial 1

Pharmacological Management

Metformin as First-Line Agent:

• Start at low dose (e.g., 500 mg daily) and gradually titrate to reduce gastrointestinal side effects 1

• Target dose typically 2000 mg daily in divided doses 1

• Benefits beyond glucose control include 1:

  • Weight neutrality
  • Low hypoglycemia risk
  • Possible cardiovascular benefits
  • Cost-effectiveness

• Contraindications for metformin 1:

  • Renal insufficiency (eGFR <45 mL/min/1.73m²)
  • Liver dysfunction
  • Severe infection or hypoxia
  • Major surgery (temporary discontinuation)
  • Use with caution and reduce dose if eGFR 45-59 mL/min/1.73m²

For Severe Hyperglycemia:

• If patient presents with significant hyperglycemic symptoms, dramatically elevated glucose (>300-350 mg/dL), or HbA1c ≥10.0%, insulin therapy should be strongly considered from the outset 1, 2
• Starting insulin regimen 2:
  • Begin with basal insulin (glargine, detemir, or NPH)
  • Starting dose: 10 IU per day
  • Titrate weekly to target fasting glucose of 72-99 mg/dL
  • Once symptoms resolve, may be possible to taper insulin and transition to oral agents 1

Special Populations

Gestational Diabetes:

• Initial management is medical nutrition therapy, physical activity, and glucose monitoring 1
• Target glucose levels:
  • Fasting <95 mg/dL
  • 1-hour postprandial <140 mg/dL or 2-hour postprandial <120 mg/dL
• If lifestyle modifications fail, insulin is the first-line pharmacological treatment in the US 1

Monitoring and Follow-up

• Regular blood glucose monitoring to guide therapy adjustments 2
• Assess HbA1c every 3 months until target achieved, then at least twice yearly 4
• Evaluate for treatment efficacy and side effects at each visit 1
• Consider medication adjustments if glycemic targets not met within 3 months 1

Common Pitfalls to Avoid

• Delaying pharmacotherapy in patients with moderate-to-severe hyperglycemia 1
• Failing to start insulin promptly when indicated by severe symptoms or metabolic decompensation 1
• Not addressing lifestyle modifications as the foundation of treatment 3
• Inadequate titration of metformin due to fear of side effects 1
• Overlooking contraindications to metformin, particularly renal impairment 1

By following this structured approach to hyperglycemia management, clinicians can effectively reduce the risk of diabetes complications while minimizing treatment-related adverse effects.