RECOGNITION AND ASSESSMENT
- For symptoms and signs, investigations and guideline to use, see Hyperglycaemia: triage guideline
Appropriate patients
- Patients with blood glucose persistently >12 mmol/L with:
- mild/no dehydration
- able to eat and drink
- no metabolic acidosis nor severe dehydration
Investigations
- Blood glucose (capillary)
- if persistently high, check venous blood glucose
MANAGEMENT
- Never give single doses of insulin (e.g. Actrapid)
- Refer to diabetes team
- Withhold metformin, gliptins and GLP analogues (exenatide and liraglutide) if:
- renal impairment (creatinine >130 µmol/L and eGFR <45 mL/min)
- decompensated cardiac failure
- liver failure or lactic acidosis
Patient on regular insulin
- Increase usual total daily insulin dose by 10–20%
Patient taking oral agents only
- Add low-dose insulin or insulin analogue
- such as 10–12 units of isophane, glargine or detemir OR
- if high risk of hypoglycaemia (e.g. elderly patient with variable oral intake), prefer glargine or detemir
- If morning fasting glucose is >12 mmol/L, add at bedtime or
- If pre-evening meal glucose is >12 mmol/L, add at breakfast time or
- If both morning fasting and pre-evening meal glucose are >12 mmol/L, add at bedtime and breakfast time
- If taking pioglitazone, be alert for appearance of dyspnoea or peripheral oedema
- introduction of insulin can precipitate heart failure
Patient on no drug treatment for diabetes
Renal impairment
- If eGFR <45 mL/min (metformin contraindicated), use sulphonylureas
Liver dysfunction
- if more than a 4-fold rise in liver enzymes:
- no oral hypoglycaemic agents
- find cause of raised liver enzymes
- use insulin, see Patient taking oral agents only above
Normal renal/liver function
- Start on metformin as first line
- irrespective of BMI
MONITOR
- Capillary blood glucose 4-hrly
DISCHARGE AND FOLLOW-UP
- Encourage early mobilisation
- Check with diabetes team about out-patient review
- If patient new to insulin, do not forget to prescribe needles for insulin pens, lancets and sharps guard
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa