What is the management for a patient with diabetes, presenting with burning pain and hyperglycemia?

Management of Burning Pain with Blood Sugar 320 mg/dL

This patient requires immediate assessment for hyperglycemic emergency (DKA or hyperosmolar hyperglycemic state) while simultaneously addressing the burning pain, which likely represents painful diabetic peripheral neuropathy requiring both acute glycemic control and specific neuropathic pain management. 1, 2

Immediate Assessment and Stabilization

Rule Out Hyperglycemic Emergency

• Check for life-threatening complications immediately: assess mental status, hydration status, presence of nausea/vomiting, ketones (urine or blood), arterial or venous pH, serum osmolality, and electrolytes 1, 2
• Calculate effective osmolality using: 2[Na+ (mEq/L)] + glucose (mg/dL)/18 2
• Blood glucose of 320 mg/dL with altered mental status, vomiting, or ketosis indicates DKA—a life-threatening emergency requiring immediate medical intervention 3, 4

Emergency Treatment Protocol (if DKA/HHS present)

• Begin immediate fluid resuscitation with 0.9% sodium chloride at 15-20 mL/kg/hour during the first hour to restore circulatory volume 1, 2
• Start insulin therapy after excluding hypokalemia (K+ <3.3 mEq/L): IV bolus of 0.1 units/kg, followed by continuous infusion at 0.1 units/kg/hour 1, 2
• Monitor blood glucose every 1-2 hours and electrolytes every 2-4 hours 1, 2
• Target glucose reduction of 50-75 mg/dL per hour initially, then maintain 140-180 mg/dL once stable 2

Glycemic Control for Non-Emergency Hyperglycemia

If No DKA/HHS Present

• Identify the cause: missed insulin doses, inadequate medication, intercurrent illness, infection, corticosteroid use, or medication non-compliance 3, 4
• Increase monitoring frequency to every 4-6 hours during acute hyperglycemia 3
• Adjust insulin regimen temporarily: patients on oral agents alone may require temporary insulin therapy 3
• Ensure adequate fluid and caloric intake 3

Transition to Maintenance

• Once blood glucose <300 mg/dL and patient able to eat, transition from IV to subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1, 2
• Implement basal-bolus regimen: 0.3-0.5 units/kg/day total, split 50/50 between basal (once daily) and bolus (with meals) insulin 2

Management of Burning Pain (Painful Diabetic Peripheral Neuropathy)

First-Line Approach

• Optimize glycemic control as the foundational step: poor or erratic glucose control contributes to neuropathic pain genesis, though evidence is observational rather than from randomized trials 3
• Note the caveat: avoid rapid glucose normalization in acute painful neuropathy, as this can paradoxically worsen symptoms 3

Pharmacological Pain Management

• Duloxetine or pregabalin are the only FDA and European Medicines Agency-approved agents for diabetic neuropathic pain 3
• Tricyclic antidepressants (TCAs) have confirmed efficacy through multiple randomized controlled trials and meta-analyses, working via inhibition of noradrenaline/serotonin reuptake in central descending pain pathways 3
• All pharmacological treatments are symptomatic only—none alter the progressive natural history of diabetic peripheral neuropathy 3

Multidisciplinary Assessment

• Evaluate pain using validated neuropathy-specific quality of life scales (NeuroQol, Norfolk Quality of Life Scale, NePIQoL) rather than generic pain scales 3
• Assess mood impact using Hospital Anxiety and Depression Scale (HADS), as depression commonly accompanies chronic neuropathic pain 3
• Address cardiovascular risk factors (hypertension, hyperlipidemia) which commonly coexist with diabetic peripheral neuropathy 3

Critical Monitoring and Follow-Up

Ongoing Surveillance

• Persistent blood glucose >300 mg/dL requires immediate medical attention 2
• Monitor for recurrent hyperglycemia patterns suggesting inadequate baseline diabetes management 3
• Ensure follow-up with endocrinology or primary care within 1-2 weeks of acute episode 2

Patient Education

• Teach recognition of hyperglycemic symptoms: drowsiness, flushed face, thirst, fruity breath odor, which can progress to nausea, vomiting, dehydration, and altered consciousness if untreated 4
• Emphasize never discontinuing insulin during illness, as this precipitates DKA 1
• Provide sick-day management education and structured discharge plan addressing underlying causes 1

Common Pitfalls to Avoid

• Do not lower glucose too rapidly: watch for cerebral edema if glucose falls >75-100 mg/dL per hour 2
• Do not assume all burning pain is neuropathic: exclude other causes and note that lipid-lowering drugs can rarely cause painful neuropathy 3
• Do not rely on symptoms alone: altered mental status with hyperglycemia can mimic intoxication or other conditions—always check blood glucose and ketones 3
• Do not overlook precipitating factors: infection, trauma, myocardial infarction, or stroke commonly trigger hyperglycemic crises 2