Management of Blood Glucose Level of 244 mg/dL
For a blood glucose level of 244 mg/dL, you should contact the provider as soon as possible and initiate or adjust glucose-lowering therapy, as this exceeds the threshold requiring intervention according to American Diabetes Association guidelines. 1
Immediate Assessment Required
Evaluate the clinical context to determine urgency of intervention: assess for symptoms of hyperglycemia (polyuria, polydipsia, altered mental status, dehydration), check vital signs, and determine if the patient is acutely ill or has any comorbid conditions 2
Rule out hyperglycemic crisis by checking for ketones in urine or blood, particularly if the patient has type 1 diabetes or presents with nausea, vomiting, or abdominal pain 2
Assess for precipitating factors including infection, medication non-adherence, new medications (especially corticosteroids), or acute illness that may be driving the hyperglycemia 1
Treatment Algorithm Based on Clinical Setting
For Hospitalized Patients
Target glucose range of 140-180 mg/dL for most hospitalized patients, which balances glycemic control with hypoglycemia risk 1, 2
Initiate basal-bolus insulin regimen for non-critically ill patients with adequate oral intake: start with basal insulin (NPH, glargine, or detemir) combined with rapid-acting prandial insulin before meals 1, 2
Use basal insulin alone for patients with poor oral intake or those receiving nothing by mouth, avoiding sliding-scale insulin as monotherapy which is strongly discouraged 1
Monitor blood glucose before each meal and at bedtime (or every 4-6 hours if not eating) to guide insulin dose adjustments 1
For Outpatients or Long-Term Care Residents
Contact the provider as soon as possible when glucose values exceed 250 mg/dL within a 24-hour period, as this meets the threshold for urgent notification 1
Initiate or intensify therapy with subcutaneous insulin if not already prescribed, starting with basal insulin and adding prandial coverage as needed 2
For patients with type 2 diabetes not on insulin, consider starting basal insulin while continuing metformin (if renal function permits), then add prandial insulin if hyperglycemia persists 2
Monitoring Strategy
Check blood glucose every 1-2 hours initially if starting insulin therapy until values stabilize, then every 4 hours thereafter 1
Adjust insulin doses daily based on blood glucose patterns rather than relying on reactive sliding-scale corrections alone 2
Use point-of-care capillary testing with caution as these measurements may not accurately reflect arterial or plasma glucose values; consider arterial blood if available 1
Critical Pitfalls to Avoid
Never use sliding-scale insulin alone without basal insulin coverage, as this approach is ineffective and increases risk of both hyperglycemia and hypoglycemia 1, 2
Do not delay insulin therapy when glucose levels are markedly elevated (>240 mg/dL), as this increases risk of progression to hyperglycemic crisis 2
Avoid tight glucose control targeting levels below 140 mg/dL in hospitalized patients, as this increases hypoglycemia risk without improving outcomes 1
Review and adjust the regimen whenever implementing changes in nutrition status, as nutrition-insulin mismatch is a common cause of both hyperglycemia and hypoglycemia 1
Special Populations
For older adults in palliative care, preventing hypoglycemia takes priority over tight control; allow glucose values in the upper range of 180-250 mg/dL to avoid hypoglycemic events 1
For critically ill patients, use continuous intravenous insulin infusion based on validated protocols, targeting glucose <180 mg/dL 1, 2
When transitioning from IV to subcutaneous insulin, start subcutaneous basal insulin at 60-80% of the daily IV insulin dose, administered 1-2 hours before discontinuing the infusion 1, 2