What interventions can be implemented to reduce glucose levels in a patient with Type 2 Diabetes Mellitus (Type II DM) and hyperglycemia?

From the Guidelines

For a hospitalized Type II diabetes patient with severe hyperglycemia in the 400 mg/dL range, immediate insulin therapy is recommended, starting with intravenous regular insulin, typically as a continuous infusion at 0.1 units/kg/hour, titrated to target glucose levels of 140-180 mg/dL, as per the most recent guidelines 1. This approach is necessary because such high glucose levels indicate severe insulin deficiency or resistance requiring immediate correction, and oral medications alone would be insufficient. The body cannot effectively utilize glucose without adequate insulin, leading to metabolic derangements that require prompt intervention to prevent complications like diabetic ketoacidosis or hyperosmolar hyperglycemic state. Some key points to consider in the management of these patients include:

• Simultaneously addressing any fluid and electrolyte imbalances, particularly checking for dehydration and potassium abnormalities, as these are common in patients with severe hyperglycemia 1.
• Once stabilized, transitioning to a subcutaneous insulin regimen with basal insulin (like glargine 0.2-0.3 units/kg/day) plus mealtime rapid-acting insulin (lispro, aspart, or glulisine at 0.05-0.1 units/kg/meal) 1.
• Continuing to monitor glucose levels every 1-2 hours initially, then every 4-6 hours when stable, to ensure that the patient's glucose levels are well-controlled and to adjust the insulin regimen as needed 1.
• Evaluating for precipitating factors such as infection, medication effects, or acute illness, as these can contribute to the development of severe hyperglycemia in patients with Type II diabetes 1.

From the FDA Drug Label

Metformin is an antihyperglycemic agent which improves glucose tolerance in patients with type 2 diabetes mellitus, lowering both basal and postprandial plasma glucose. Insulin Initiation and Intensification of Glucose Control Intensification or rapid improvement in glucose control has been associated with a transitory, reversible ophthalmologic refraction disorder, worsening of diabetic retinopathy, and acute painful peripheral neuropathy.

For a type II DM patient with hyperglycemia (400's) in the hospital, insulin therapy should be considered to reduce glucose levels.

• Glargine (SQ) can be used to achieve glucose control, but it is essential to monitor the patient's glucose levels and adjust the dosage as needed to avoid hypoglycemia.
• Metformin (PO) can also be used to improve glucose tolerance, but its effectiveness in rapidly reducing glucose levels in a hospital setting may be limited. It is crucial to carefully evaluate the patient's condition and medical history before initiating any treatment, and to closely monitor their response to therapy 2, 3.

From the Research

Management of Hyperglycemia in Type 2 Diabetes

To reduce glucose levels in a type II DM patient with hyperglycemia (400's) in the hospital, the following steps can be taken:

• Initial management: According to 4, current guidelines recommend insulin for patients with type 2 diabetes and severe hyperglycemia, but non-insulin treatments may also be effective in this setting.
• Medications: Metformin is the first choice of medication in T2DM patients, as stated in 5. Other options include sulfonylureas, glinides, α-glucosidase inhibitors, thiazolidinediones, incretin mimetics, and SGLT2 inhibitors.
• Combination therapy: The combination of metformin and SGLT2 inhibitors may be a better option in improving glycemic control with a low risk of hypoglycemia, but an increase in the risk of metabolic acidosis during combination therapy should be considered, as mentioned in 6.
• Patient characteristics: Predictors of success in achieving glucose lowering include newly diagnosed T2D, certified diabetes educator visits, and less time to follow-up, as found in 4.

Treatment Options

Some treatment options for type 2 diabetes include:

• Metformin: a first-line treatment that reduces hepatic glucose production, as described in 7 and 8.
• SGLT2 inhibitors: a new class of oral antihyperglycemic agents that decrease blood glucose level by increasing urinary glucose excretion, as mentioned in 5 and 6.
• Insulin therapy: may be used in patients with severe hyperglycemia, but did not result in better glycemic control compared to non-insulin regimens in one study, as reported in 4.

Considerations

When managing hyperglycemia in type 2 diabetes, the following should be considered:

• Risk of hypoglycemia: some medications, such as sulfonylureas, have a high risk of hypoglycemia, while others, such as metformin and SGLT2 inhibitors, have a low risk, as stated in 5 and 6.
• Risk of metabolic acidosis: the combination of metformin and SGLT2 inhibitors may increase the risk of metabolic acidosis, as mentioned in 6.
• Patient characteristics: newly diagnosed patients may be more likely to achieve glucose lowering with non-insulin therapy, as found in 4.