What is the best approach to manage a diabetic patient with severe hyperglycemia?

Management of Severe Hyperglycemia with Metabolic Acidosis

This patient requires immediate insulin therapy due to blood glucose of 358 mg/dL combined with a CO2 of 10 mEq/L, which indicates metabolic acidosis and possible diabetic ketoacidosis (DKA). 1, 2

Immediate Assessment and Stabilization

• Check for ketones immediately (serum or urine) to confirm DKA, as the combination of severe hyperglycemia (358 mg/dL) and low bicarbonate (CO2 10 mEq/L) strongly suggests ketoacidosis requiring urgent treatment 1, 2

• Assess for symptoms of DKA including polyuria, polydipsia, nausea, vomiting, abdominal pain, altered mental status, or Kussmaul respirations 1

• If ketones are present or the patient is symptomatic/mentally obtunded, continuous intravenous regular insulin is the standard of care for DKA management 1

• If ketones are absent and the patient is alert and stable, subcutaneous insulin can be initiated 1, 2

Insulin Initiation Strategy

For patients with marked hyperglycemia (≥250 mg/dL) who are symptomatic, initiate basal insulin immediately while starting or continuing metformin. 2

• Start with basal insulin (NPH, insulin glargine, or insulin detemir) at an initial dose of 0.1-0.2 units/kg/day, typically 10 units once daily if weight-based dosing is not feasible 1, 2

• Add rapid-acting insulin analog (insulin aspart, lispro, or glulisine) before meals at approximately 4 units per meal or 50% of total daily insulin divided among three meals if basal insulin alone is insufficient 2, 3

• Rapid-acting insulin should be administered within 5-10 minutes before meals 4

Medication Adjustments

• Discontinue sulfonylureas (if the patient is taking them) once insulin is started to reduce hypoglycemia risk 1, 2, 3

• Continue metformin unless contraindicated, as it complements insulin therapy 1, 2

• SGLT2 inhibitors should be held in the setting of possible DKA, as they can cause euglycemic ketoacidosis 1

Titration Protocol

• Increase basal insulin by 2-4 units every 3 days until fasting glucose reaches 100-120 mg/dL 3

• Target fasting and premeal blood glucose of 80-130 mg/dL and two-hour postprandial glucose <180 mg/dL 5

• Monitor blood glucose at least 4 times daily (fasting and before each meal) during titration 1, 4

Critical Monitoring Requirements

• Increase frequency of blood glucose monitoring during any insulin regimen changes, as changes in insulin type, dose, or injection site can predispose to hypoglycemia or hyperglycemia 4

• Monitor for hypoglycemia symptoms including confusion, sweating, tremor, and altered consciousness, which can occur suddenly and impair concentration 4

• Patients with renal or hepatic impairment are at higher risk for hypoglycemia and may require more conservative dosing 4

Patient Education Essentials

• Provide comprehensive education on glucose monitoring, insulin injection technique, insulin storage, recognition and treatment of hypoglycemia, and "sick day" rules before discharge 1, 2

• Instruct patients to always check insulin labels before each injection to avoid medication errors between insulin products 4

• Educate on proper injection site rotation (abdomen, thigh, buttocks, upper arm) to prevent lipodystrophy, which can cause erratic insulin absorption and hyperglycemia 4

• Emphasize that needles and syringes must never be shared due to risk of blood-borne pathogen transmission 4

Post-Stabilization Management

• Once glucose toxicity resolves and symptoms improve, insulin may be tapered by 10-30% every few days over 2-6 weeks, potentially transitioning partially or entirely to non-insulin agents 2

• Reassess glycemic status every 3 months with HbA1c to determine if continued insulin therapy is necessary 2

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients with glucose ≥300 mg/dL, HbA1c ≥10%, or symptoms of hyperglycemia, as this represents profound insulin deficiency 2

• Do not continue sulfonylureas with multiple daily insulin injections, as this significantly increases hypoglycemia risk without substantial glycemic benefit 3

• Do not mix insulin aspart with any other insulin in the same syringe 4

• Avoid injecting into areas of lipodystrophy, as this can result in unpredictable insulin absorption and hyperglycemia 4