What is the recommended next step for a patient with hyperglycemia (elevated blood glucose level) of 260 mg/dL?

Management of Blood Glucose of 260 mg/dL

For a patient with blood glucose of 260 mg/dL, the immediate next step depends critically on whether this is an inpatient or outpatient setting and whether the patient has symptoms of diabetic ketoacidosis (DKA). 1

Initial Assessment

First, determine if the patient requires hospitalization by checking for DKA or hyperosmolar hyperglycemic state (HHS):

• Obtain venous blood gases, serum electrolytes, blood urea nitrogen, creatinine, and urine ketones immediately to rule out DKA (diagnostic criteria: blood glucose >250 mg/dL, venous pH <7.3, bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia) 1
• Check for HHS (diagnostic criteria: blood glucose >600 mg/dL, venous pH >7.3, bicarbonate >15 mEq/L, and altered mental status or severe dehydration) 1
• Assess for symptoms including polyuria, polydipsia, fatigue, Kussmaul respiration, altered mental status, or severe dehydration 1

If DKA or HHS is Present (Inpatient Management)

Hospitalize immediately and initiate continuous IV insulin infusion at 0.1 units/kg/hour, targeting a glucose decline of 50-75 mg/dL per hour until glucose reaches 200-250 mg/dL 1

• Begin fluid resuscitation with isotonic saline (0.9% NaCl) at 10-20 mL/kg/h for the first hour 2
• Add potassium supplementation (20-40 mEq/L) once renal function is confirmed and serum potassium is known 2
• Monitor serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours 1

If No DKA/HHS (Outpatient Insulin Initiation)

For asymptomatic patients without ketoacidosis or severe dehydration, initiate insulin therapy as an outpatient with a total daily insulin dose of 0.3-0.5 units/kg/day 1

Preferred Insulin Regimen

Use a basal-bolus insulin regimen with 50% of the total daily dose given as basal insulin (long-acting) and 50% as prandial insulin (rapid-acting before meals) 1

• For a 70 kg patient: Total daily dose = 21-35 units/day (0.3-0.5 units/kg)
• Basal insulin (glargine or detemir): 10-17 units once daily 3, 4
• Prandial insulin (rapid-acting): 3-6 units before each of three meals 1

Common pitfall to avoid: Do not use sliding scale insulin alone without basal coverage, as basal-bolus regimens have superior outcomes in preventing complications 1

If Already Hospitalized (Non-Critical Care)

For hospitalized patients without critical illness, insulin therapy should be initiated if blood glucose is persistently ≥180 mg/dL (checked on two occasions), with a target glucose range of 140-180 mg/dL 2

• For noncritically ill patients, a target range of 100-180 mg/dL is acceptable 2
• Perform point-of-care glucose monitoring before meals if eating, or every 4-6 hours if not eating 2
• Use scheduled basal-bolus-correction insulin rather than sliding scale alone 5

Monitoring and Titration

Monitor fasting blood glucose daily and check blood glucose at least 4 times daily during the titration phase 1

• Use fasting plasma glucose values to titrate basal insulin 6
• Use both fasting and postprandial glucose values to titrate mealtime insulin 6
• Recheck HbA1c in 3 months to assess treatment effectiveness 1

Patient Education

Educate the patient to never stop insulin during illness, even when not eating, to prevent DKA 1

• Teach recognition of hypoglycemia symptoms (confusion, sweating, tremor, rapid heartbeat) 2
• Instruct on maintaining hydration with non-caloric fluids during illness 1
• Emphasize the importance of carrying a source of sugar at all times 2
• Recommend wearing a medical alert bracelet or necklace 2

Additional Considerations

If the patient has type 2 diabetes and is not yet on insulin, consider adding metformin after metabolic stabilization, as this combination is associated with decreased weight gain, lower insulin dose, and less hypoglycemia compared to insulin alone 6

• Do not abruptly discontinue oral medications when starting insulin therapy due to risk of rebound hyperglycemia 6
• For patients with renal or hepatic impairment, insulin requirements may need adjustment and hypoglycemia risk is higher 3, 4