How is hyperglycemia managed?

Management of Hyperglycemia

For patients with severe hyperglycemia (blood glucose ≥250 mg/dL, HbA1c ≥10%, or symptomatic with polyuria/polydipsia/weight loss), initiate insulin therapy immediately in combination with lifestyle intervention, as this provides the most rapid and effective glycemic control. 1, 2

Outpatient/Ambulatory Management

Initial Assessment and Treatment Selection

Severity-Based Treatment Algorithm:

• Severe hyperglycemia with catabolic features (fasting glucose ≥250 mg/dL, random glucose >300 mg/dL, HbA1c ≥10%, ketonuria, or symptoms of polyuria/polydipsia/weight loss): Start insulin therapy immediately with lifestyle intervention 1, 2

• Moderate hyperglycemia (HbA1c 7.5-10%): Initiate metformin at diagnosis along with lifestyle modifications 1

• Mild hyperglycemia (HbA1c <7.5%) in highly motivated patients: May attempt lifestyle changes alone for 3-6 months before adding metformin 1

Glycemic Targets for Outpatients

Individualized HbA1c targets based on patient characteristics: 1

• Standard target: HbA1c <7.0% (mean glucose 150-160 mg/dL, fasting <130 mg/dL, postprandial <180 mg/dL) for most patients 1

• More stringent targets (HbA1c 6.0-6.5%) for patients with short disease duration, long life expectancy, no significant cardiovascular disease, if achievable without hypoglycemia 1

• Less stringent targets (HbA1c 7.5-8.0% or higher) for patients with history of severe hypoglycemia, limited life expectancy, advanced complications, extensive comorbidities 1

Medication Selection for Uncontrolled Hyperglycemia on Metformin

When metformin alone is insufficient: 2

• Add basal insulin (glargine or detemir preferred over NPH due to less overnight hypoglycemia and slightly less weight gain) for patients with marked hyperglycemia or symptoms 2

• Insulin plus metformin is particularly effective for lowering glycemia while limiting weight gain 1

• If basal insulin alone inadequate, progress to basal-bolus regimen by adding rapid-acting insulin analogs before meals 2

Critical Patient Education for Insulin Initiation

Mandatory education components before discharge: 2

• Glucose monitoring techniques and frequency
• Insulin injection technique and proper storage
• Recognition and treatment of hypoglycemia
• Self-adjustment of insulin doses based on glucose trends

Inpatient/Hospital Management

Critical Care Setting

Continuous intravenous insulin infusion is the standard of care for critically ill patients with hyperglycemia. 1

• Target glucose range: 140-180 mg/dL (avoid tighter targets as they increase hypoglycemia without improving outcomes) 1, 3

• Starting threshold: no higher than 180 mg/dL for initiating IV insulin 3

• Use validated written or computerized protocols with predefined adjustments 1

• Monitor blood glucose every 30 minutes to 2 hours during IV insulin infusion 1

Noncritical Care Setting

Scheduled insulin regimens are strongly preferred over sliding-scale insulin alone. 1, 2

For patients with good nutritional intake: 1, 3

• Basal-bolus regimen (basal insulin + prandial rapid/short-acting insulin + correction insulin) is the preferred treatment 1
• This approach improves glycemic outcomes and reduces perioperative complications compared to correction-only insulin 1

For patients with poor or no oral intake: 1, 3

• Basal insulin alone (single dose of long-acting insulin) plus correction insulin every 4-6 hours 1, 3
• Monitor glucose every 4-6 hours in patients not eating 1

For patients eating meals: 1

• Perform bedside glucose monitoring before each meal 1

Perioperative Management

Specific perioperative glucose targets and medication adjustments: 1

• Target range: 80-180 mg/dL (tighter targets do not improve outcomes and increase hypoglycemia) 1

• Hold metformin on the day of surgery 1

• Discontinue SGLT2 inhibitors 3-4 days before surgery 1

• Hold other oral agents the morning of surgery 1

• Give half of NPH dose or 75-80% of long-acting analog dose based on diabetes type 1

• Reduce evening-before-surgery insulin by 25% to achieve better perioperative glucose control with lower hypoglycemia risk 1

Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

Management priorities for DKA/HHS: 1

• Restore circulatory volume and tissue perfusion
• Resolve hyperglycemia with continuous IV insulin in critically ill/obtunded patients 1
• Correct electrolyte imbalances and acidosis
• Treat underlying precipitants (sepsis, MI, stroke) 1

Critical transition step: Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1

Common Pitfalls and How to Avoid Them

Avoid sliding-scale insulin as monotherapy - basal-bolus regimens provide superior glycemic control 2

Do not delay insulin initiation in symptomatic patients or those with very high glucose levels, as early intervention prevents metabolic decompensation 2

Metformin contraindications to monitor: 2

• Hold in patients with eGFR <30 mL/min/1.73 m²
• Discontinue with acute illness involving hypoxia/shock
• Temporarily withhold before contrast imaging studies 4

Avoid excessively tight glucose targets in hospitalized patients (maintaining <180 mg/dL minimizes symptoms without adversely affecting outcomes) 3, 4

Monitor for hypoglycemia risk when combining insulin with metformin or other glucose-lowering agents 2, 5

Ensure proper discharge planning with medication reconciliation, diabetes education, and scheduled follow-up to reduce readmission rates 1