DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
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) and SGLT2 inhibitor if:
- renal impairment as defined by 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 long-acting insulin or insulin analogue
- such as 10–12 units of isophane, glargine, detemir, semglee, degludec or toujeo
- if high risk of hypoglycaemia (e.g. elderly patient with variable oral intake), prefer glargine semglee, degludec or toujeo to isophane or determir
- 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 liver dysfunction as well, follow next section on Liver dysfunction
- Otherwise, if eGFR <45 mL/min (metformin contraindicated), use sulfonylureas
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
- starting dose 500 mg once daily; routinely in order to reduce frequency of administration and improve compliance, advice is given to increase dose to 500 mg twice daily after 1 week - gradually maximised to 1 g twice daily
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