What are the recommendations for managing uncontrolled blood sugar levels in patients with type 2 diabetes?

Management of Uncontrolled Blood Sugar in Type 2 Diabetes

For patients with uncontrolled type 2 diabetes, a stepwise approach starting with metformin as first-line therapy, followed by rapid addition of medications when glycemic targets are not achieved, and early initiation of insulin therapy for severely uncontrolled cases is recommended. 1

Initial Assessment and Treatment Strategy

• Lifestyle interventions including diet modifications and physical activity should be implemented and maintained throughout the course of diabetes management, but should not delay pharmacological intervention 1
• Metformin should be initiated concurrently with lifestyle interventions at diagnosis, unless contraindicated 1
• Patient-centered approach should guide the choice of additional pharmacologic agents based on efficacy, hypoglycemia risk, effect on weight, cost, side effects, and patient preferences 1

Management Based on Severity of Hyperglycemia

For Severely Uncontrolled Diabetes:

• In patients with fasting glucose ≥250 mg/dL, random glucose consistently >300 mg/dL, HbA1c >10%, or presence of ketonuria, or symptomatic diabetes with polyuria, polydipsia, and weight loss, insulin therapy combined with lifestyle intervention is the treatment of choice 1
• Insulin can be titrated rapidly and provides the greatest likelihood of quickly returning glucose levels to target 1
• After symptoms are relieved and glucose levels decrease, oral agents can often be added and insulin may potentially be withdrawn if preferred 1

For Moderately Uncontrolled Diabetes:

• For patients with HbA1c ≥8.5% who are symptomatic, consider initiating basal insulin while starting metformin 1
• For patients with marked hyperglycemia (blood glucose ≥250 mg/dL, HbA1c ≥8.5%) without acidosis who are symptomatic, treat initially with basal insulin while metformin is initiated and titrated 1
• In patients with ketosis/ketoacidosis, treatment with insulin (subcutaneous or intravenous) should be initiated to rapidly correct hyperglycemia and metabolic derangement 1

For Mild to Moderate Hyperglycemia:

• In metabolically stable patients (HbA1c <8.5% and asymptomatic), metformin is the initial pharmacologic treatment of choice if renal function is normal 1
• If glycemic targets are not achieved after approximately 3 months, consider adding a second agent 1

Combination Therapy Approach

• When adding second antihyperglycemic medications, consider drugs with different mechanisms of action for greatest synergy 1
• Insulin plus metformin is particularly effective for lowering glycemia while limiting weight gain 1
• For patients with established cardiovascular disease, chronic kidney disease, or heart failure, a sodium-glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular benefit is recommended as part of the glucose-lowering regimen 1
• In patients with type 2 diabetes, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible 1

Treatment Intensification

• Treatment intensification for patients not meeting glycemic targets should not be delayed 1
• The medication regimen should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed 1
• For patients treated with basal insulin who do not meet glycemic targets, consider advancing to multiple daily injections with basal and premeal bolus insulins 1
• If glycemic targets are no longer met with metformin (with or without basal insulin), consider adding other agents such as GLP-1 receptor agonists 1

Special Considerations

• For patients with hypoglycemia concerns (e.g., those with hazardous jobs), consider medications with lower risk of hypoglycemia 1
• For patients where weight management is a priority, consider agents that promote weight loss (e.g., GLP-1 receptor agonists) 1
• In youth with type 2 diabetes, a reasonable HbA1c target when treated with oral agents alone is <7%, with more stringent targets (<6.5%) appropriate for selected patients if achievable without significant hypoglycemia 1
• Less stringent HbA1c goals (such as 7.5%) may be appropriate if there is increased risk of hypoglycemia 1

Monitoring and Follow-up

• Glycemic status should be assessed every 3 months 1
• Home self-monitoring of blood glucose regimens should be individualized based on the pharmacologic treatment 1
• Regular evaluation of medication-taking behavior is essential for optimal management 1

By following this structured approach to managing uncontrolled blood sugar in type 2 diabetes, clinicians can help patients achieve and maintain glycemic targets, thereby reducing the risk of diabetes-related complications and improving quality of life.