What is the treatment for a patient with a hemoglobin A1c (HbA1c) level of 14?

Treatment of HbA1c 14%

For a patient with HbA1c of 14%, immediately initiate basal insulin at 0.5 units/kg/day along with metformin, while simultaneously assessing for ketosis/ketoacidosis and symptomatic hyperglycemia. 1

Immediate Assessment Required

• Check for ketosis/ketoacidosis immediately by measuring serum and urine ketones, as this severe hyperglycemia mandates urgent evaluation for metabolic derangement 1, 2
• Assess for symptoms of marked hyperglycemia including polyuria, polydipsia, nocturia, and weight loss, which indicate need for immediate insulin therapy 1
• Obtain comprehensive metabolic panel to evaluate renal function (eGFR) and electrolytes before initiating therapy 3
• If blood glucose ≥600 mg/dL, evaluate for hyperglycemic hyperosmolar nonketotic syndrome 1

Treatment Algorithm Based on Clinical Presentation

If Ketosis/Ketoacidosis Present:

• Initiate subcutaneous or intravenous insulin immediately to rapidly correct hyperglycemia and metabolic derangement 1, 2
• Once acidosis resolves (pH >7.3, bicarbonate >18 mEq/L), start metformin while continuing subcutaneous insulin therapy 1, 2
• Monitor arterial or venous blood gases every 2-4 hours until pH >7.3 2
• Check serum electrolytes (particularly potassium) every 2-4 hours, maintaining potassium between 4-5 mEq/L 2

If Marked Hyperglycemia WITHOUT Acidosis:

• Start basal insulin at 0.5 units/kg/day (typically long-acting insulin glargine administered once daily at bedtime) 1, 3
• Simultaneously initiate metformin 500 mg twice daily with meals if eGFR >30 mL/min, titrating to 1000 mg twice daily over 1-2 weeks 1, 4
• Titrate basal insulin every 2-3 days based on blood glucose monitoring to achieve fasting glucose 140-180 mg/dL initially 1, 3

Comprehensive Management Strategy

Diabetes Self-Management Education:

• Provide comprehensive diabetes self-management education and support that is culturally appropriate at the time of diagnosis 1
• Implement medical nutrition therapy emphasizing nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages 1
• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week 3

Monitoring Protocol:

• Assess glycemic status every 3 months with HbA1c measurement 1
• Implement blood glucose monitoring individualized to the pharmacologic treatment, with multiple daily checks when on insulin 1
• Offer real-time continuous glucose monitoring (CGM) or intermittently scanned CGM for patients on multiple daily injections who are capable of using the device safely 1
• Monitor for hypoglycemia during initial insulin titration phase 3

Treatment Escalation if Goals Not Met

After Initial Stabilization:

• If glycemic targets are not met with metformin and basal insulin after 3 months, add a GLP-1 receptor agonist approved for type 2 diabetes (if age ≥10 years and no contraindications such as personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2) 1
• If still not at goal with metformin, GLP-1 receptor agonist, and basal insulin, transition to multiple daily injections with basal and premeal bolus insulins or insulin pump therapy 1

Long-Term Glycemic Targets:

• Target HbA1c <7% (53 mmol/mol) for most patients once stabilized 1, 3
• More stringent targets (such as <6.5%) may be appropriate for selected patients with short duration of diabetes and lesser degrees of beta-cell dysfunction if achievable without significant hypoglycemia 1
• Less stringent targets (such as <8%) may be appropriate for individuals with history of severe hypoglycemia or limited life expectancy 1, 3

Critical Pitfalls to Avoid

• Never delay insulin initiation in patients with HbA1c ≥8.5% who are symptomatic, as this risks worsening metabolic decompensation and diabetic ketoacidosis 1, 3, 4
• Do not use metformin if eGFR <30 mL/min due to increased lactic acidosis risk 4
• Avoid overly aggressive correction of severe hyperglycemia to prevent rapid fluid shifts and electrolyte abnormalities 3
• Do not assume type 2 diabetes without checking pancreatic autoantibodies if ketosis/ketoacidosis present, as diabetes type may be uncertain initially 1

Special Considerations for Youth

• In children and adolescents with HbA1c ≥8.5% and symptomatic hyperglycemia, the same approach applies: initiate basal insulin while starting metformin 1
• Youth require particularly close monitoring and family involvement in diabetes management tasks 1