What are the management strategies for hyperglycemia?

From the Guidelines

Management Strategies for Hyperglycemia

Management of hyperglycemia involves a multifaceted approach, including lifestyle modifications and pharmacological interventions. Insulin therapy should be initiated for the treatment of persistent hyperglycemia at a glucose level of $180 mg/dL (10.0 mmol/L)$, with a target glucose range of $140–180 mg/dL (7.8–10.0 mmol/L)$ for the majority of critically ill patients 1.

• For noncritically ill patients, the target range is $100–180 mg/dL (5.6–10.0 mmol/L)$, with basal insulin dosing based on body weight and expected sensitivity to insulin 1.
• Correction insulin may be used to correct hyperglycemia, with the dose adjusted based on the patient's glucose level and insulin sensitivity.
• For patients with mild-to-moderate hyperglycemia, a basal-plus approach with or without non-insulin agents may simplify treatment regimens and reduce the risk of hypoglycemia 1.
• Dipeptidyl peptidase-4 inhibitors (DPP-4i), such as sitagliptin, may be used in patients with mild hyperglycemia, especially those who are insulin-naive or have a low HbA1c level on admission 1.
• Glucagon should be prescribed for patients at risk of severe hypoglycemia, and their close contacts should be instructed on how to administer it 1.

Key Considerations

• Hypoglycemia is a major limiting factor in glycemic management, and patients should be educated on situations that increase their risk, such as fasting, exercise, and sleep 1.
• Individualized treatment targets should be based on patient preferences, risk of adverse effects, and patient characteristics, including frailty and comorbid conditions 1.
• Comprehensive management of hyperglycemia should include lifestyle modifications, such as medical nutrition therapy, physical activity, and weight loss, as well as pharmacological interventions 1.

From the FDA Drug Label

Patients should be informed about potential risks and advantages of LEVEMIR therapy, including the possible side effects Patients should be offered continued education and advice on insulin therapies, injection technique, life-style management, regular glucose monitoring, periodic glycosylated hemoglobin testing, recognition and management of hypo- and hyperglycemia, adherence to meal planning, complications of insulin therapy, timing of dosage, instruction for use of injection devices and proper storage of insulin Patients should be informed that frequent, patient-performed blood glucose measurements are needed to achieve effective glycemic control to avoid both hyperglycemia and hypoglycemia Physician Counseling Information for Patients In initiating treatment for type 2 diabetes, diet should be emphasized as the primary form of treatment Caloric restriction and weight loss are essential in the obese diabetic patient. Proper dietary management alone may be effective in controlling the blood glucose and symptoms of hyperglycemia.

The management strategies for hyperglycemia include:

• Lifestyle management: diet, exercise, and weight loss
• Monitoring: regular glucose monitoring and periodic glycosylated hemoglobin testing
• Medication management: adjustment of insulin dosage or administration of oral hypoglycemic agents like glipizide
• Patient education: recognition and management of hyperglycemia, adherence to meal planning, and proper storage of insulin 2, 3

From the Research

Management Strategies for Hyperglycemia

The management of hyperglycemia involves various strategies, including lifestyle modifications, oral medications, and insulin therapy.

• Lifestyle Modifications: Structured education and dietary interventions can effectively control blood glucose levels without pharmacological intervention, as seen in patients with newly diagnosed type 2 diabetes mellitus (T2DM) 4.
• Oral Medications: Various oral medications, such as metformin, sulfonylureas, thiazolidinediones, and dipeptidyl peptidase-4 inhibitors, can be used as initial monotherapy for T2DM patients with contraindications or intolerance to metformin 5.
• Insulin Therapy: Insulin is the primary treatment for patients with type 1 diabetes mellitus (T1DM) and can be used in combination with oral medications for T2DM patients 6. The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin, alone or in combination with other oral antidiabetic drugs (OADs) 6.
• Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RAs): GLP-1RAs, such as exenatide and liraglutide, can offer superior benefit compared to insulin in reducing HbA1c levels and are associated with weight loss, rather than weight gain 7.
• Perioperative Management: In the perioperative setting, hyperglycemia can be managed through screening, monitoring, and treatment with oral hypoglycemics and insulin therapy, with a target blood glucose level of < 180 mg/dL (10 mmol/L) 8.

Key Considerations

When managing hyperglycemia, it is essential to consider the individual patient's needs and characteristics, such as their type of diabetes, comorbidities, and lifestyle.

• Target Blood Glucose Levels: The target blood glucose level for patients with T1DM is < 7.5% (< 58 mmol/mol) 6, while for T2DM patients, the target is < 7% (< 53 mmol/mol) 7.
• Monitoring and Titration: Blood glucose monitoring is an integral part of effective insulin therapy, and fasting plasma glucose (FPG) values should be used to titrate basal insulin, while both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin 6.
• Combination Therapy: Combination therapy, such as metformin combined with insulin, can be effective in reducing HbA1c levels and is associated with decreased weight gain, lower insulin dose, and less hypoglycemia 6.