What are the management instructions for a patient with hyperglycemia?

Management Instructions for Patients with Hyperglycemia

Immediate Assessment and Recognition

If you have severe hyperglycemia (blood glucose >250 mg/dL), you need immediate medical evaluation to rule out diabetic ketoacidosis (DKA), especially if you have type 1 diabetes. 1

• Watch for warning signs requiring emergency care: excessive urination, extreme thirst, nausea, vomiting, abdominal pain, confusion, or fruity-smelling breath 1
• Check for ketones in your urine or blood if you have a home testing kit and your glucose is >250 mg/dL 1
• Seek immediate medical attention if you have ketones present, are vomiting, or have altered mental status 2

Blood Glucose Monitoring at Home

• Check your blood glucose at least before each meal and at bedtime (4 times daily minimum) when experiencing hyperglycemia 2
• Keep a written log of all readings with dates and times to share with your healthcare provider 2
• If you use continuous glucose monitoring (CGM) and are familiar with the technology, continue using it for more frequent monitoring 2

Target Blood Glucose Goals

• Aim for blood glucose levels between 140-180 mg/dL (7.8-10.0 mmol/L) during illness or acute hyperglycemia 2, 1
• Contact your healthcare provider if readings consistently exceed 180 mg/dL despite following your treatment plan 2
• Do not attempt to achieve glucose levels below 140 mg/dL on your own, as this increases risk of dangerous low blood sugar 3

Medication Management

Never stop your basal insulin (long-acting insulin like Lantus/glargine or Levemir/detemir) even when your blood sugar is high—this is a critical error that worsens hyperglycemia. 4

If You Take Insulin:

• Continue your prescribed basal (long-acting) insulin at the scheduled time every day 4
• Use rapid-acting insulin (lispro, aspart, or glulisine) before meals as prescribed by your provider 2, 1
• Apply correction doses of rapid-acting insulin for blood glucose >250 mg/dL: typically 2 units for glucose 250-350 mg/dL and 4 units for glucose >350 mg/dL, but confirm your specific correction scale with your provider 4
• Do not rely on sliding-scale insulin alone without basal insulin—this approach is ineffective and strongly discouraged 4, 5

If You Take Oral Medications:

• Continue metformin if your kidney function is normal 1
• Take other oral diabetes medications as prescribed unless instructed otherwise by your provider 2
• Stop SGLT2 inhibitors (medications like empagliflozin, dapagliflozin, canagliflozin) immediately and contact your provider, as these can cause dangerous complications during severe hyperglycemia 2

Hydration and Nutrition

• Drink at least 8-10 glasses of water daily to prevent dehydration from high blood sugar 2
• Avoid sugar-sweetened beverages, fruit juices, and regular sodas 2
• Continue eating regular meals even if your appetite is reduced—skipping meals while on insulin increases risk of dangerous blood sugar swings 2
• If unable to eat solid foods, consume carbohydrate-containing liquids (sugar-free options preferred) to maintain some caloric intake 2

Physical Activity Modifications

• Avoid vigorous exercise when blood glucose is >250 mg/dL, especially if ketones are present 1
• Light walking (10-15 minutes after meals) may help lower blood glucose if you feel well enough and ketones are absent 6
• Resume normal exercise only after blood glucose is consistently below 180 mg/dL 6

When to Seek Medical Care

Call 911 or Go to Emergency Department If:

• Blood glucose remains >400 mg/dL despite treatment 2
• You have ketones in urine/blood with nausea, vomiting, or abdominal pain 2, 1
• You experience confusion, extreme drowsiness, or difficulty staying awake 2
• You have rapid breathing or shortness of breath 2

Contact Your Healthcare Provider Within 24 Hours If:

• Blood glucose consistently >250 mg/dL for more than 2 consecutive readings 2
• You experience persistent nausea without vomiting 1
• You have signs of infection (fever, painful urination, cough with colored sputum) 2
• You are unsure how to adjust your insulin doses 2

Hypoglycemia Prevention and Treatment

While treating hyperglycemia, you must also watch for low blood sugar (hypoglycemia), which can occur if insulin doses are too aggressive. 2

• Recognize hypoglycemia symptoms: shakiness, sweating, rapid heartbeat, confusion, hunger, or irritability 2
• Treat blood glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate (4 glucose tablets, 4 oz fruit juice, or 1 tablespoon honey) 2
• Recheck blood glucose after 15 minutes and repeat treatment if still <70 mg/dL 2
• If you cannot swallow or are unconscious, someone should administer intranasal or injectable glucagon and call 911 2

Follow-Up Care

• Schedule an appointment with your primary care provider or endocrinologist within 1 week if experiencing new or worsening hyperglycemia 2, 1
• Bring your blood glucose log to all appointments 2
• Discuss medication adjustments based on your glucose patterns—do not adjust doses on your own without provider guidance 1
• Request hemoglobin A1c testing if not done in the past 3 months to assess overall glucose control 6

Critical Pitfalls to Avoid

• Never use sliding-scale insulin alone without basal insulin—this is the most common error leading to poor glucose control 4, 5
• Never stop or reduce basal insulin when blood sugar is high—this causes further deterioration 4
• Never delay seeking medical care for persistent severe hyperglycemia (>400 mg/dL) or symptoms of DKA 2, 1
• Never take SGLT2 inhibitors during acute illness or severe hyperglycemia 2
• Never skip meals while taking mealtime insulin, as this causes dangerous glucose fluctuations 2

Medication Storage and Handling

• Store unopened insulin in the refrigerator; opened vials/pens can be kept at room temperature for up to 28 days 7
• Inspect insulin before each use—it should be clear and colorless (for rapid-acting and long-acting analogs); discard if cloudy or discolored 7
• Rotate injection sites within the same body area (abdomen, thighs, arms) to prevent lipodystrophy and ensure consistent absorption 7