What is the treatment for hyperglycemia with a blood sugar level exceeding 500 mg/dL?

Management of Blood Sugar Over 500 mg/dL

For blood sugar exceeding 500 mg/dL, immediate treatment with insulin therapy is essential, with intravenous insulin infusion being the preferred method for critically ill patients and subcutaneous insulin with basal-bolus regimen for stable patients. 1, 2

Initial Assessment

• Evaluate for symptoms of hyperglycemic crisis including polyuria, polydipsia, nausea, vomiting, abdominal pain, altered mental status, and signs of dehydration 2
• Check for ketones in urine or blood to rule out diabetic ketoacidosis (DKA), especially in patients with type 1 diabetes 2, 3
• Assess vital signs, hydration status, and mental status to determine if this represents an emergency requiring immediate intervention 2, 4
• The presence of ketonuria with severe hyperglycemia is highly concerning for evolving diabetic ketoacidosis (DKA), which requires immediate emergency department management 3

Treatment Protocol

For Critically Ill Patients:

• Initiate continuous intravenous insulin infusion using validated protocols 1, 2
• Target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for most critically ill patients 1
• More stringent goals (110-140 mg/dL) may be appropriate for selected patients (e.g., cardiac surgery patients) if achievable without significant hypoglycemia 1
• For IV insulin therapy, use ultra-rapid insulin diluted to a concentration of 1 IU/mL 2
• Monitor blood glucose every hour until stable, then every 2 hours 2
• Provide simultaneous glucose infusion (100-150 g/day) once blood glucose falls below 250 mg/dL to prevent hypoglycemia 2, 5

For Non-Critically Ill Patients:

• Initiate subcutaneous insulin therapy with a basal-bolus regimen 1, 2
• Start with basal insulin (long-acting analog such as glargine or detemir) 1
• Add prandial insulin (rapid-acting analog such as aspart, lispro, or glulisine) before meals 1
• Avoid using sliding scale insulin alone as it is ineffective and strongly discouraged 1, 2
• For patients with type 2 diabetes with marked hyperglycemia, start with basal insulin while initiating metformin (if renal function is normal) 1, 2

For Hyperglycemic Crisis (DKA or HHS):

• Administer IV fluids for rehydration (0.9% sodium chloride) to restore circulating volume 2, 6
• Initiate insulin therapy (IV insulin for DKA; IV or subcutaneous for HHS without significant ketosis) 2, 6
• Monitor and replace electrolytes, especially potassium 2, 5, 6
• Identify and treat the underlying precipitant (infection, medication non-adherence, new-onset diabetes) 6, 4

Monitoring and Adjustment

• Adjust insulin doses daily based on blood glucose patterns 2
• For patients on IV insulin, transition to subcutaneous insulin when stable, starting subcutaneous insulin 1-2 hours before discontinuing IV insulin 2
• Target glucose range of 140-180 mg/dL for most hospitalized patients 1
• Monitor for hypoglycemia, which is one of the most frequent adverse events with insulin therapy 5
• Check electrolytes regularly, particularly potassium, as insulin therapy can cause hypokalemia 5, 6

Common Pitfalls to Avoid

• Delaying insulin therapy for severe hyperglycemia increases risk of complications 2, 7
• Using sliding scale insulin alone without basal insulin is ineffective and strongly discouraged 1, 2
• Inadequate monitoring of blood glucose can lead to both persistent hyperglycemia and hypoglycemic events 2, 5
• Failing to identify and treat the underlying cause of severe hyperglycemia 6, 4
• Overlooking the risk of cerebral edema with too rapid correction of severe hyperglycemia, especially in children and young adults 6

Follow-up Care

• For patients transitioning to outpatient care, schedule follow-up within 1 week to 1 month 2
• Provide education on medication management, blood glucose monitoring, and hypoglycemia prevention before discharge 2, 7
• Consider resuming oral medications 1-2 days before discharge if appropriate 1