What medication is recommended for a woman with severe hyperglycemia (glucose level of 500) and poorly controlled diabetes (A1c of 12)?

Insulin Therapy for Severe Hyperglycemia in a Woman with A1c of 12% and Glucose of 500 mg/dL

Immediate insulin therapy is required for this patient with severe hyperglycemia (glucose 500 mg/dL) and poorly controlled diabetes (A1c 12%). This level of hyperglycemia represents a medical emergency requiring prompt intervention to prevent complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state.

Initial Management

• Intravenous (IV) regular insulin should be initiated immediately for rapid correction of severe hyperglycemia, especially with glucose levels of 500 mg/dL 1, 2
• Initial IV insulin infusion should follow validated protocols that allow for predefined adjustments based on glycemic fluctuations 3
• Fluid resuscitation must be provided concurrently to address dehydration commonly associated with severe hyperglycemia 3, 2
• Electrolyte monitoring and replacement (particularly potassium) is essential as insulin therapy will drive potassium into cells 1

Hospital Management

• Target blood glucose range of 140-180 mg/dL is appropriate for most hospitalized patients with hyperglycemia 3, 4
• When transitioning from IV to subcutaneous insulin, administer subcutaneous insulin 1-2 hours before discontinuing IV insulin to prevent rebound hyperglycemia 3
• Convert to basal insulin at 60-80% of the daily IV infusion dose when transitioning 3

Long-term Management Plan

• After stabilization, implement a basal-bolus insulin regimen rather than sliding scale insulin alone, which is strongly discouraged 3, 4
• For patients with HbA1c ≥9%, a combination therapy approach is recommended to achieve glycemic control more quickly 5
• Basal insulin (long-acting) should be initiated at 0.1-0.2 units/kg/day, with titration by 2 units every 3 days until fasting blood glucose reaches target 5
• Prandial insulin should be added starting with 4 units per meal or 10% of the basal dose 5

Monitoring and Follow-up

• Self-monitoring of blood glucose should be performed regularly to guide treatment adjustments 5
• HbA1c should be rechecked after 3 months to assess treatment effectiveness 5
• For women with diabetes who may become pregnant, target HbA1c <6% if achievable without significant hypoglycemia 3
• Regular monitoring for hypoglycemia is essential, as it is one of the most frequent adverse events with insulin therapy 1

Special Considerations

• Assess for precipitating causes of hyperglycemia such as infection, medication changes, or other stressors 3
• Patient education on recognizing and managing hypoglycemia is crucial, as symptoms may include sweating, dizziness, tremor, and confusion 1
• Patients should always carry a quick source of sugar (hard candy, glucose tablets) to treat hypoglycemia 1
• Insulin requirements may increase with certain medications such as corticosteroids, oral contraceptives, or thyroid replacement therapy 1

This severe level of hyperglycemia requires immediate medical attention and likely hospitalization for initial stabilization. Once stabilized, a structured discharge plan tailored to the individual patient should be implemented to prevent readmission and ensure continued glycemic control 3.