Treatment of Hyperglycemic Chorea
The primary treatment for hyperglycemic chorea is aggressive glycemic control with insulin therapy, targeting blood glucose levels of 100-180 mg/dL, which typically leads to resolution of choreiform movements within days to weeks. 1, 2, 3
Immediate Management
Glycemic Control (First-Line Treatment)
- Initiate intravenous insulin infusion for severe hyperglycemia (glucose >300 mg/dL), starting with a bolus of 0.15 U/kg body weight followed by continuous infusion at 0.1 U/kg/h 4
- Target blood glucose reduction of 50-75 mg/dL per hour until reaching 100-180 mg/dL range 4, 5
- Gradual glucose correction over 48 hours is critical - rapid correction does not improve outcomes and may increase complications 1, 3
- Monitor blood glucose every 2-4 hours during acute management 5
Symptomatic Control of Chorea
- Dopamine-blocking or dopamine-depleting medications (such as haloperidol) can be used for severe, disabling choreiform movements while awaiting glucose normalization 1, 2
- Low-dose clonazepam (benzodiazepine) is an alternative for symptomatic control 6
- These medications are adjunctive only - glycemic control remains the definitive treatment 2, 3
Clinical Course and Monitoring
Expected Timeline
- Chorea typically resolves within 1-2 weeks after achieving glycemic control in most cases 2, 3
- In some patients, complete resolution occurs within 2-5 days of glucose normalization 6
- Persistent chorea beyond 1 week despite glucose control may require continued dopamine-blocking therapy 2
Diagnostic Confirmation
- Brain imaging shows characteristic findings: T1-hyperintense basal ganglia (particularly putamen and caudate) on MRI in approximately 50% of cases 2, 3
- CT may show hyperdense lentiform and caudate nuclei 3, 6
- These radiological changes resolve rapidly (within 2-4 weeks) following glycemic control, confirming the diagnosis 6
Long-Term Management
Prevention of Recurrence
- Transition to subcutaneous basal-bolus insulin regimen before discontinuing IV insulin, administering basal insulin 2-4 hours prior to stopping the infusion 5
- Maintain HbA1c <7-8% to prevent recurrence - in reported cases, chorea did not recur when glucose control was sustained 1, 3
- Provide diabetes education emphasizing the importance of medication adherence and never discontinuing insulin 4
Follow-Up
- Outpatient endocrinology follow-up within 1 week to 1 month after discharge 5
- Monitor HbA1c every 3 months initially to ensure sustained glycemic control 3
Important Clinical Pearls
- Hyperglycemic chorea is rare (approximately 1% of all chorea cases) but should be considered in elderly patients with poorly controlled diabetes presenting with acute hemichorea 2
- Most commonly affects elderly Asian women (median age 80 years) with longstanding or new-onset diabetes 2, 3
- Unilateral presentation is typical (seen in 6/7 cases in one series), which may be mistaken for stroke 2
- Absence of ketones is characteristic - this is a non-ketotic hyperglycemic complication 1, 6
- Do not use sliding-scale insulin alone - basal-bolus regimens are required for effective glycemic control 5