What are the initial steps and treatment options for managing hyperglycemia (high blood sugar)?

Management of Hyperglycemia

For patients with hyperglycemia, initial treatment should include lifestyle modifications combined with metformin as first-line pharmacologic therapy, with additional medications or insulin added based on symptom severity, glucose levels, and A1C values. 1

Initial Assessment and Classification

• Evaluate symptom severity (polyuria, polydipsia, nocturia, weight loss) and measure blood glucose and A1C to determine appropriate initial treatment approach 1
• Check for ketosis/ketoacidosis which requires immediate insulin therapy 1
• For severe hyperglycemia (blood glucose ≥600 mg/dL), assess for hyperglycemic hyperosmolar nonketotic syndrome 1

Lifestyle Management (Foundation of All Treatment)

• Implement healthful nutrition focusing on nutrient-dense foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages 1, 2
• Encourage regular physical activity: at least 30-60 minutes of moderate-to-vigorous physical activity 5 days/week with strength training 3 days/week 1
• Consider meal timing and sequence: consuming protein and vegetables first, followed by carbohydrates 30 minutes later can moderate glucose levels 2
• Post-meal moderate exercise (30-60 minutes after eating) can blunt glucose surges 2, 3

Pharmacologic Treatment Algorithm

For Metabolically Stable Patients (A1C <8.5%, asymptomatic)

1. Start with metformin as initial pharmacologic therapy if renal function is normal 1
2. Begin at low dose and gradually titrate to minimize gastrointestinal side effects 1, 4
3. If glycemic targets not met after 3 months, consider adding:
   • GLP-1 receptor agonist (preferred option for patients ≥10 years old) 1
   • SGLT2 inhibitor (empagliflozin) for patients ≥10 years old 1

For Symptomatic Patients with Marked Hyperglycemia (Blood glucose ≥250 mg/dL, A1C ≥8.5%)

1. Start with basal insulin plus metformin 1
2. Monitor blood glucose regularly and adjust insulin dose as needed 1, 5
3. Once glucose levels stabilize, consider tapering insulin by decreasing dose 10-30% every few days while continuing metformin 1

For Patients with Ketosis/Ketoacidosis

1. Initiate subcutaneous or intravenous insulin immediately to correct hyperglycemia and metabolic derangement 1
2. Once acidosis resolves, start metformin while continuing insulin therapy 1
3. Consider gradual insulin taper if glycemic targets are maintained 1

Insulin Therapy Considerations

• For basal insulin, consider long-acting analogs (insulin glargine or detemir) which have less overnight hypoglycemia than NPH 1, 5
• If A1C remains above goal on basal insulin, consider progression to multiple daily injections with basal and prandial insulin 1
• Adjust insulin doses based on blood glucose monitoring, targeting individualized glycemic goals 1, 5
• For patients on insulin, educate about proper injection technique, insulin storage, and hypoglycemia recognition/treatment 1, 5

Monitoring and Follow-up

• Assess glycemic status every 3 months with A1C testing 1
• Individualize glycemic targets based on patient factors, with a reasonable A1C target of <7% for most patients on oral agents alone 1
• Consider more stringent targets (A1C <6.5%) for selected patients with short duration of diabetes and less β-cell dysfunction 1
• Consider less stringent targets (A1C ~7.5%) if increased risk of hypoglycemia 1

Special Considerations

• For patients with high baseline A1C (≥9-10%), consider starting with combination therapy or insulin from the outset 1
• Monitor for medication side effects: hypoglycemia with insulin 5, gastrointestinal effects with metformin 4
• For patients with severe hyperglycemia but without evidence of type 1 diabetes, insulin may be tapered once symptoms resolve 1
• Comprehensive cardiovascular risk reduction should be a major focus of therapy alongside glycemic control 1