Management Of Acute Hyperglycemia In Type 2 Diabetes

Management Of Persistent Hyperglycemia In Type 2 Diabetes Mellitus

The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc. All topics are updated as new evidence becomes available and our peer review process is complete. INTRODUCTION — Initial treatment of patients with type 2 diabetes mellitus includes education, with emphasis on lifestyle changes including diet, exercise, and weight reduction when appropriate. Monotherapy with metformin is indicated for most patients, and insulin may be indicated for initial treatment for some [1]. Although several studies have noted remissions of type 2 diabetes mellitus that may last several years, most patients require continuous treatment in order to maintain normal or near-normal glycemia. Bariatric surgical procedures in obese patients that result in major weight loss have been shown to lead to remission in a substantial fraction of patients. Regardless of the initial response to therapy, the natural history of most patients with type 2 diabetes is for blood glucose concentrations to rise gradually with time. Treatment for hyperglycemia that fails to respond to initial monotherapy and long-term pharmacologic therapy in type 2 diabetes is reviewed here. Options for initial therapy and other therapeutic issues in diabetes management, such as the frequency of monitoring and evaluation for microvascular and macrovascular complications, are discussed separately. (See "Initial management of blood glucose in adults with type 2 diabetes mellitus" and "Overview of medical care in adults with diabetes mellitus". Continue reading >>

Hyperglycemia And Type 2 Diabetes

Part 1 of 6 Highlights High blood glucose, or hyperglycemia, primarily affects those with diabetes. If left untreated it can lead to chronic complications, such as kidney disease or nerve damage. Good diabetes management and careful blood glucose monitoring are both effective ways of preventing hyperglycemia. High blood glucose, or hyperglycemia, can cause major health complications in people with diabetes over time. Several factors can contribute to hyperglycemia, including eating more carbohydrates than normal and being less physically active than normal. Regular blood sugar testing is crucial for people with diabetes, because many people do not feel the symptoms of high blood sugar. Part 2 of 6 Short-term symptoms of high blood sugar include: excessive thirst excessive urination increased urination at night blurry vision sores that won’t heal fatigue If you experience symptoms of hyperglycemia, it’s important that you check your blood glucose levels. Untreated high blood sugar can lead to chronic complications, such as eye, kidney, or heart disease or nerve damage. The symptoms listed above can develop over several days or weeks. The longer the condition is left untreated, the more severe the problem may become. Generally, blood glucose levels greater than 180 mg/dL after meals — or over 130 mg/dL before eating — are considered high. Be sure to check with your doctor to learn your blood sugar targets. Part 3 of 6 A number of conditions or factors can contribute to hyperglycemia, including: eating more carbohydrates than usual being less physically active than usual being ill or having an infection experiencing high levels of stress not getting the right dosage of glucose-lowering medication Part 4 of 6 There are several treatment methods available for hypergl Continue reading >>

Management Of Diabetes Mellitus In Hospitalized Patients

INTRODUCTION Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes [1,2]. In one study, 25 percent of patients with type 1 diabetes and 30 percent with type 2 diabetes had a hospital admission during one year; patients with higher values for glycated hemoglobin (A1C) were at highest risk for admission [2]. The prevalence of diabetes rises with increasing age, as does the prevalence of other diseases; both factors increase the likelihood that an older person admitted to a hospital will have diabetes. The treatment of patients with diabetes who are admitted to the general medical wards of the hospital for a procedure or intercurrent illness is reviewed here. The treatment of hyperglycemia in critically ill patients, the perioperative management of diabetes, and the treatment of complications of the diabetes itself, such as diabetic ketoacidosis, are discussed separately. (See "Glycemic control and intensive insulin therapy in critical illness" and "Perioperative management of blood glucose in adults with diabetes mellitus" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment" and "Management of hypoglycemia during treatment of diabetes mellitus".) GOALS IN THE HOSPITAL SETTING The main goals in patients with diabetes needing hospitalization are to minimize disruption of the metabolic state, prevent adverse glycemic events (especially hypoglycemia), return the patient to a stable glycemic balance as quickly as possible, and ensure a smooth transition to outpatient care. These goals are not always easy to achieve. On the one hand, the stress of the acute illness tends to raise blood glucose concentrations. On the other hand, the anorexia that often a Continue reading >>

Individualizing Treatment Of Hyperglycemia In Type 2 Diabetes

From the University of Arizona College of Pharmacy and the University of Arizona College of Medicine-Tucson, Tucson, AZ. ABSTRACT • Objective: To summarize key issues relevant to managing hyperglycemia in patients with type 2 diabetes mellitus (T2DM) and review a strategy for initiating and intensifying therapy. • Methods: Review of the literature. • Results: The 6 most widely used pharmacologic treatment options for hyperglycemia in T2DM are metformin, sulfonylureas, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, and insulin. Recent guidelines stress the importance of an individualized, patient-centered approach to managing hyperglycemia in T2DM, although sufficient guidance for nonspecialists on how to individualize treatment is often lacking. For patients with no contraindications, metformin should be recommended concurrent with lifestyle intervention at the time of diabetes diagnosis. Due to the progressive nature of T2DM, glycemic control on metformin monotherapy is likely to deteriorate over time, and there is no consensus as to what the second-line agent should be. A second agent should be selected based on glycemic goal and potential advantages and disadvantages of each agent for any given patient. If the patient progresses to the point where dual therapy does not provide adequate control, either a third non-insulin agent or insulin can be added. • Conclusion: Although research is increasingly focusing on what the ideal number and sequence of drugs should be when managing T2DM, investigating all possible combinations in diverse patient populations is not feasible. Physicians therefore must continue to rely on clinical judgment to determine how to apply trial data to the treatment o Continue reading >>

Management Of Hyperglycemia In Type 2 Diabetes: A Consensus Algorithm For The Initiation And Adjustment Of Therapy

Injections, three times/day dosing, frequent GI side effects, expensive, little experience *Severe hypoglycemia is relatively infrequent with sulfonylurea therapy. The longer-acting agents (e.g. chlorpropamide, glyburide [glibenclamide], and sustained-release glipizide) are more likely to cause hypoglycemia than glipizide, glimepiride, and gliclazide. Repaglinide is more effective at lowering A1C than nateglinide. GI, gastrointestinal. 1)Begin with low-dose metformin (500 mg) taken once or twice per day with meals (breakfast and/or dinner). 2)After 57 days, if GI side effects have not occurred, advance dose to 850 or 1,000 mg before breakfast and dinner. 3)If GI side effects appear as doses advanced, can decrease to previous lower dose and try to advance dose at a later time. 4)The maximum effective dose is usually 850 mg twice per day, with modestly greater effectiveness with doses up to 3 g per day. GI side effects may limit the dose that can be used. 5)Based on cost considerations, generic metformin is the first choice of therapy. A longer-acting formulation is available in some countries and can be given once per day. Injections, three times/day dosing, frequent GI side effects, expensive, little experience *Severe hypoglycemia is relatively infrequent with sulfonylurea therapy. The longer-acting agents (e.g. chlorpropamide, glyburide [glibenclamide], and sustained-release glipizide) are more likely to cause hypoglycemia than glipizide, glimepiride, and gliclazide. Repaglinide is more effective at lowering A1C than nateglinide. GI, gastrointestinal. David M. Nathan, MD,1 John B. Buse, MD, PHD,2 Mayer B. Davidson, MD,3 Robert J. Heine, MD,4 Rury R. Holman, FRCP,5 Robert Sherwin, MD 6 and Bernard Zinman, MD 7 1 Diabetes Center, Massachusetts General Hospital and Harv Continue reading >>

Hyperglycemia - Symptoms, Causes And Treatments

Hyperglycemia is a term referring to high blood glucose levels - the condition that often leads to a diagnosis of diabetes. High blood glucose levels are the defining feature of diabetes, but once the disease is diagnosed, hyperglycemia is a signal of poor control over the condition. Hyperglycemia is defined by certain high levels of blood glucose:1 Fasting levels greater than 7.0 mmol/L (126 mg/dL) Two-hours postprandial (after a meal) levels greater than 11.0 mmol/L (200 mg/dL). Chronic hyperglycemia usually leads to the development of diabetic complications.2 Symptoms of hyperglycemia The most common symptoms of diabetes itself are related to hyperglycemia - the classic symptoms of frequent urination and thirst.2,3 Typical signs and symptoms of hyperglycemia that has been confirmed by blood glucose measurement include:1,3,4 Thirst and hunger Dry mouth Frequent urination, particularly at night Tiredness Recurrent infections, such as thrush Weight loss Vision blurring. Causes of hyperglycemia Hyperglycemia often leads to the diagnosis of diabetes. For people already diagnosed and treated for diabetes, however, poor control over blood sugar levels leads to the condition. Causes of this include:1,3,4 Eating more or exercising less than usual Insufficient amount of insulin treatment (more commonly in cases of type 1 diabetes) Insulin resistance in type 2 diabetes Illness such as the flu Psychological and emotional stress The "dawn phenomenon" or "dawn effect" - an early morning hormone surge. The video below from Diabetes UK explains the dawn phenomenon and offers practical tips. Treatment and prevention of hyperglycemia Prevention of hyperglycemia for people with a diabetes diagnosis is a matter of good self-monitoring and management of blood glucose levels, including ad Continue reading >>

Initial Management Of Severe Hyperglycemia In Patients With Type 2 Diabetes: An Observational Study

Initial Management of Severe Hyperglycemia in Patients with Type 2 Diabetes: an Observational Study University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO USA University of Colorado Hospital, Aurora, CO USA Jennifer M. Trujillo, Email: [email protected] . Current guidelines recommend insulin for patients with type 2 diabetes (T2D) and severe hyperglycemia, but this recommendation lacks sufficient evidence and poses practical challenges. It is unclear whether non-insulin treatments are effective in this setting. The objective of this study was to describe treatment strategies of T2D patients with severe hyperglycemia and identify which initial treatments, interventions, or patient characteristics correlated with successful glucose lowering. This was a retrospective cohort study of 114 patients with T2D and a glycosylated hemoglobin (A1C) 12%. Changes in A1C were compared between patients started on non-insulin medications versus insulin-based regimens. Regression analysis was performed to assess predictors of success in achieving A1C 9% within 1year. The main outcomes measures were change in A1C from baseline and predictors of success in achieving A1C 9% within 1year. At baseline, 43 patients (37.7%) started one or more non-insulin medications; 71 (62.3%) started insulin. Fifty-eight patients (50.8%) achieved an A1C 9%. Predictors of success were newly diagnosed T2D, certified diabetes educator (CDE) visits, and less time to follow-up A1C; insulin therapy was not. Change in A1C was significantly better in the non-insulin cohort compared to the insulin cohort (4.5% vs. 2.8%, p=0.001). Newly diagnosed patients were less likely to start insulin therapy (20.8% vs. 73.3%, p<0.001), less likely to use insulin at any point (29.2% Continue reading >>

Hyperglycemia In Diabetes

Print Diagnosis Your doctor sets your target blood sugar range. For many people who have diabetes, Mayo Clinic generally recommends target blood sugar levels that are: Between 80 and 120 mg/dL (4 and 7 mmol/L) for people age 59 and younger who have no other underlying medical conditions Between 100 and 140 mg/dL (6 and 8 mmol/L) for people age 60 and older, those who have other medical conditions, such as heart, lung or kidney disease, or those who have a history of low blood sugar (hypoglycemia) or who have difficulty recognizing the symptoms of hypoglycemia Your target blood sugar range may differ, especially if you're pregnant or you develop diabetes complications. Your target blood sugar range may change as you get older, too. Sometimes, reaching your target blood sugar range is a challenge. Home blood sugar monitoring Routine blood sugar monitoring with a blood glucose meter is the best way to be sure that your treatment plan is keeping your blood sugar within your goal range. Check your blood sugar as often as your doctor recommends. If you have any signs or symptoms of severe hyperglycemia — even if they're subtle — check your blood sugar level. If your blood sugar level is 240 mg/dL (13 mmol/L) or above, use an over-the-counter urine ketones test kit. If the urine test is positive, your body may have started making the changes that can lead to diabetic ketoacidosis. You'll need your doctor's help to lower your blood sugar level safely. Glycated hemoglobin (A1C) test During an appointment, your doctor may conduct an A1C test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. An A1C level of 7 perc Continue reading >>

Management Of Severe/acute Hyperglycemia In Hospitalised Type 2 Diabetes Mellitus Patients Pages 9-14

Abstract: Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder comprising 90% of all diabetes worldwide. T2DM is characterized by hyperglycemia resulting from insufficient secretion of insulin by beta cells of pancreas, peripheral insulin resistance and accompanied by impaired regulation of hepatic gluconeogenesis. T2DM can be classified into acute complication and chronic complication. Severe/acute hyperglycemia is an acute complication of T2DM, which commonly seen in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). DKA and HHS are acute metabolic complications caused by absolute or relative deficiency in endogenous insulin level. The presence of severe/acute hyperglycemia is often associated with increasing hospital stays, worsening of infection, post-discharge disability and death. Hence, insulin therapy is the method that most preferred to treat severe/acute hyperglycemia and controlling glycemic level in hospital setting. The subcutaneous insulin administration is the most frequently used in non-critically ill patients admitted to hospital. Management of severe/acute hyperglycemia involves basal-bolus insulin versus sliding–scale insulin and continuous insulin infusion versus subcutaneous insulin infusion. This review focuses on treatment option savailable in hospitalised T2DM patients with acute hyperglycemia. Keywords: Acute hyperglycemia, type 2 diabetes mellitus, insulin, sliding scale, basal-bolus. Continue reading >>

Hyperglycemia

Not to be confused with the opposite disorder, hypoglycemia. Hyperglycemia, or high blood sugar (also spelled hyperglycaemia or hyperglycæmia) is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/l (200 mg/dl), but symptoms may not start to become noticeable until even higher values such as 15–20 mmol/l (~250–300 mg/dl). A subject with a consistent range between ~5.6 and ~7 mmol/l (100–126 mg/dl) (American Diabetes Association guidelines) is considered slightly hyperglycemic, while above 7 mmol/l (126 mg/dl) is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person's renal threshold of glucose and overall glucose tolerance. On average however, chronic levels above 10–12 mmol/L (180–216 mg/dL) can produce noticeable organ damage over time. Signs and symptoms[edit] The degree of hyperglycemia can change over time depending on the metabolic cause, for example, impaired glucose tolerance or fasting glucose, and it can depend on treatment.[1] Temporary hyperglycemia is often benign and asymptomatic. Blood glucose levels can rise well above normal and cause pathological and functional changes for significant periods without producing any permanent effects or symptoms. [1] During this asymptomatic period, an abnormality in carbohydrate metabolism can occur which can be tested by measuring plasma glucose. [1] However, chronic hyperglycemia at above normal levels can produce a very wide variety of serious complications over a period of years, including kidney damage, neurological damage, cardiovascular damage, damage to the retina or damage to feet and legs. Diabetic n Continue reading >>

Sliding-scale Versus Basal-bolus Insulin In The Management Of Severe Or Acute Hyperglycemia In Type 2 Diabetes Patients: A Retrospective Study

Abstract Sliding-scale and basal-bolus insulin regimens are two options available for the treatment of severe or acute hyperglycemia in type 2 diabetes mellitus patients. Although its use is not recommended, sliding-scale insulin therapy is still being used widely. The aims of the study were to compare the glycemic control achieved by using sliding-scale or basal-bolus regimens for the management of severe or acute hyperglycemia in patients with type 2 diabetes and to analyze factors associated with the types of insulin therapy used in the management of severe or acute hyperglycemia. This retrospective study was conducted using the medical records of patients with acute or severe hyperglycemia admitted to a hospital in Malaysia from January 2008 to December 2012. A total of 202 patients and 247 admissions were included. Patients treated with the basal-bolus insulin regimen attained lower fasting blood glucose (10.8±2.3 versus 11.6±3.5 mmol/L; p = 0.028) and mean glucose levels throughout severe/acute hyperglycemia (12.3±1.9 versus 12.8±2.2; p = 0.021) compared with sliding-scale insulin regimens. Diabetic ketoacidosis (p = 0.043), cardiovascular diseases (p = 0.005), acute exacerbation of bronchial asthma (p = 0.010), and the use of corticosteroids (p = 0.037) and loop diuretics (p = 0.016) were significantly associated with the type of insulin regimen used. In conclusion, type 2 diabetes patients with severe and acute hyperglycemia achieved better glycemic control with the basal-bolus regimen than with sliding-scale insulin, and factors associated with the insulin regimen used could be identified. Figures Citation: Zaman Huri H, Permalu V, Vethakkan SR (2014) Sliding-Scale versus Basal-Bolus Insulin in the Management of Severe or Acute Hyperglycemia in Type 2 Diabe Continue reading >>

Management Of Hyperglycemic Crises In Patients With Diabetes

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are two of the most serious acute complications of diabetes. These hyperglycemic emergencies continue to be important causes of morbidity and mortality among patients with diabetes in spite of major advances in the understanding of their pathogenesis and more uniform agreement about their diagnosis and treatment. The annual incidence rate for DKA estimated from population-based studies ranges from 4.6 to 8 episodes per 1,000 patients with diabetes (1,2), and in more recent epidemiological studies in the U.S., it was estimated that hospitalizations for DKA during the past two decades are increasing (3). Currently, DKA appears in 4-9% of all hospital discharge summaries among patients with diabetes (4,5). The incidence of HHS is difficult to determine because of the lack of population-based studies and the multiple combined illnesses often found in these patients. In general, it is estimated that the rate of hospital admissions due to HHS is lower than the rate due to DKA and accounts for <1% of all primary diabetic admissions (4,5,6). Treatment of patients with DKA and HHS uses significant health care resources, which increases health care costs. In 1983, the cost of hospitalization for DKA in Rhode Island for 1 year was estimated to be $225 million (2). It was recently reported that treatment of DKA episodes represents more than one of every four health care dollars spent on direct medical care for adult patients with type 1 diabetes and for one of every two dollars in those patients experiencing multiple episodes of ketoacidosis (7). Based on an annual average of ∼100,000 hospitalizations for DKA in the U.S. (4) and estimated annual mean medical care charges of ∼$13,000 per patient experiencing Continue reading >>

Management Of Inpatient Hyperglycemia And Diabetes In Older Adults

Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65–75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient’s clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management. The global burden of diabetes has increased significantly during the past two decades and is expected to affect more than 642 million adults by 2040 Continue reading >>

Management Of Blood Glucose In Type 2 Diabetes Mellitus

Evidence-based guidelines for the treatment of type 2 diabetes mellitus focus on three areas: intensive lifestyle intervention that includes at least 150 minutes per week of physical activity, weight loss with an initial goal of 7 percent of baseline weight, and a low-fat, reduced-calorie diet; aggressive management of cardiovascular risk factors (i.e., hypertension, dyslipidemia, and microalbuminuria) with the use of aspirin, statins, and angiotensin-converting enzyme inhibitors; and normalization of blood glucose levels (hemoglobin A1C level less than 7 percent). Insulin resistance, decreased insulin secretion, and increased hepatic glucose output are the hallmarks of type 2 diabetes, and each class of medication targets one or more of these defects. Metformin, which decreases hepatic glucose output and sensitizes peripheral tissues to insulin, has been shown to decrease mortality rates in patients with type 2 diabetes and is considered a first-line agent. Other medications include sulfonylureas and nonsulfonylurea secretagogues, alpha glucosidase inhibitors, and thiazolidinediones. Insulin can be used acutely in patients newly diagnosed with type 2 diabetes to normalize blood glucose, or it can be added to a regimen of oral medication to improve glycemic control. Except in patients taking multiple insulin injections, home monitoring of blood glucose levels has questionable utility, especially in relatively well-controlled patients. Its use should be tailored to the needs of the individual patient. Type 2 diabetes mellitus, the sixth leading cause of death in the United States, is directly responsible for more than 73,000 deaths annually and is a contributing factor in more than 220,000 deaths.1 It is the leading cause of kidney failure and new cases of blindness in a Continue reading >>

Initial Management Of Severe Hyperglycemia In Type 2 Diabetes

Initial Management of Severe Hyperglycemia in Type 2 Diabetes Shauna Runchey, MD and Irl B Hirsch, M.D. Fellow in Metabolism, Endocrinology & Nutrition, University of Washington, Seattle Professor of Metabolism, Endocrinology & Nutrition, University of Washington, Seattle Type 2 diabetes mellitus (DM) is a common disease affecting 26 million people, 8.3% of the US population. Of these, an estimated 7 million people are undiagnosed. Type 2 DM typically has two pathophysiologic defects: an insulin secretory defect and insulin resistance. Symptoms of uncontrolled hyperglycemia include polyuria, polydipsia, blurry vision and possibly dehydration and weight loss. Patients may complain of thirst, sweet cravings, generalized fatigue, abdominal discomfort, and muscle cramps. They may have a history of poor wound healing and/or frequent infections. Basic metabolic laboratory tests may reveal a random blood glucose level over 200 mg/dL [11.1 mmol/L], hyper- or hyponatremia, hypokalemia, metabolic acid-base derangements and acute renal or prerenal insufficiency. Historical clues for the diagnosis of type 2 DM might include pre-existing history of pre-diabetes, a family history of type 2 diabetes, an ethnicity at higher risk for DM (African-American, Hispanic, Native American, Pacific Islander), a history of gestational diabetes, obesity, and sedentary lifestyle. Insulin resistance, insulin deficiency (pancreatic beta cell failure), increased gluconeogenesis, glycogenolysis Glycosuric calorie loss and inadequate glucose utilization Lactic acid accumulation, hypokalemia, electrolyte /acid-base derangements Metabolic alkalosis and/or acidosis, electrolyte disturbances Insulin deficiency resulting in lipolysis yielding free fatty acids, substrate for formation of ketone bodies Diabet Continue reading >>