Treatment for High Blood Sugars
Metformin is the first-line pharmacologic treatment for hyperglycemia in type 2 diabetes, unless contraindicated, and should be initiated at diagnosis along with comprehensive lifestyle modifications including dietary changes and physical activity. 1
Initial Assessment and Treatment Approach
- Treatment should be initiated based on the severity of hyperglycemia and presence of symptoms 1:
- For mild hyperglycemia (A1C <8.5%, asymptomatic): Start with metformin if kidney function is normal 1
- For marked hyperglycemia (blood glucose ≥250 mg/dL, A1C ≥8.5%) with symptoms: Begin with long-acting insulin while initiating metformin 1
- For severe hyperglycemia with ketoacidosis: Start insulin therapy (IV or subcutaneous) to correct metabolic derangement, then add metformin once acidosis resolves 1
- For severe hyperglycemia (blood glucose ≥600 mg/dL): Evaluate for hyperosmolar hyperglycemic state and treat with fluid replacement and insulin 2
Lifestyle Modifications
- Implement comprehensive lifestyle programs that include 1:
- At least 60 minutes of moderate to vigorous physical activity daily with muscle and bone strength training at least 3 days/week 1
- Weight management with an initial goal of 7-10% decrease in excess weight 1, 3
- Nutrition focused on non-starchy vegetables, whole fruits, legumes, whole grains, nuts, seeds, and low-fat dairy products 1
- Reduced consumption of meat, sugar-sweetened beverages, sweets, refined grains, and processed foods 1
Pharmacologic Management
First-Line Therapy
- Metformin is the preferred initial agent due to its effectiveness, safety, low cost, and potential to reduce cardiovascular events 1, 4
- Common side effects include gastrointestinal intolerance, which can be mitigated by gradual dose titration 4
- Monitor vitamin B12 levels periodically as metformin may cause deficiency 1
Additional Therapy Options
- If glycemic goals are not met with metformin alone, consider adding 1:
- Glucagon-like peptide-1 (GLP-1) receptor agonist for patients ≥10 years old 1
- Sodium-glucose cotransporter 2 inhibitor (SGLT2i) such as empagliflozin for patients ≥10 years old 1
- For patients with established cardiovascular disease or high cardiovascular risk, prioritize GLP-1 receptor agonists or SGLT2 inhibitors 1, 3
Insulin Therapy
- Insulin should be considered when 1:
- Hyperglycemia is severe, especially with catabolic features (weight loss, hypertriglyceridemia, ketosis)
- Other agents are ineffective in achieving glycemic targets
- For patients initially treated with insulin who achieve glycemic goals, insulin can be tapered by decreasing the dose 10-30% every few days 1
Monitoring and Follow-up
- Medication regimen should be reevaluated every 3-6 months and adjusted based on glycemic control and patient factors 1
- For patients on insulin, watch for signs of overbasalization (basal dose >0.5 IU/kg/day, hypoglycemia, high glycemic variability) 1
- Monitor for hypoglycemia, especially in patients taking insulin or sulfonylureas 4
Special Considerations
For hyperosmolar hyperglycemic state (blood glucose ≥600 mg/dL), initial management includes 2:
- Fluid replacement with 0.9% NaCl at 15-20 ml/kg/hour initially
- Insulin therapy at 0.1 units/kg/hour after excluding hypokalemia
- Monitoring blood glucose hourly during acute phase
- Transitioning to subcutaneous insulin when stable with a dose of 60-80% of total daily IV insulin dose
When choosing medications, consider 1:
- Comorbidities (cardiovascular disease, kidney disease, heart failure)
- Risk of hypoglycemia
- Effects on body weight
- Side effect profile
- Cost and patient preferences
Common Pitfalls to Avoid
- Delaying treatment intensification when glycemic goals are not met 1
- Failing to consider cardiovascular and renal benefits of newer agents (GLP-1 receptor agonists, SGLT2 inhibitors) 1, 3
- Not addressing lifestyle modifications alongside pharmacologic therapy 1, 5
- Overlooking the need for vitamin B12 monitoring in patients on long-term metformin therapy 1