Management and Disposition of Adults with New-Onset Hyperglycemia without Hyperglycemic Emergency

Authors: Xavier Schwartz, MD (EM Resident Physician, University of Vermont Medical Center); Alison Sullivan, MD, MS (Assistant Professor of Emergency Medicine, University of Vermont Medical Center) // Reviewed by: Andrew Grock, MD (Assistant Professor of Emergency Medicine, David Geffen School of Medicine at UCLA / Staff Physician, Greater LA VA Hospital System); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Cases

Case 1: A 45-year-old man presents to the Emergency Department (ED) with atypical chest pain: sharp, left-sided, worst with movement, better after taking ibuprofen. He denies nausea, diaphoresis, radiation, pleuritic pain, hemoptysis, lightheadedness, worsening with exertion. He has a past medical history of well-controlled hypertension and no significant family history. Physical exam reveals normal vital signs, pain with range of motion of the left shoulder, and tenderness to palpation over the left pectoral muscle and anterior shoulder. His cardiac workup reveals an unremarkable ECG and two negative troponins. His other labs are within normal limits except for a glucose of 174 mg/dL (9.7 mmol/L). Though he can be safely discharged from a chest pain evaluation, what should you do about his elevated glucose?

Case 2: A 57-year-old man with a past medical history (PMH) of hypertension, obesity, and hyperlipidemia presents to the ED with high blood sugar on a routine blood draw today. He reports increased thirst and urinary frequency over the last several weeks but otherwise feels well. He denies lightheadedness/dizziness, dysuria, chest pain, shortness of breath, abdominal pain, nausea, vomiting, and other review of systems (ROS) is also negative. He reports that his doctor told him he had “early diabetes” a few years ago, which he has managed with lifestyle interventions. Vitals are within normal limits. Exam shows a well-appearing, overweight male with dry mucous membranes. Blood glucose (BG) is 265 mg/dL (14.7 mmol/L). His labs reveal no ketones, gap, acidosis, or hyperosmolar state. How should we manage his blood sugar?

Clinical Question: What is the ED management and disposition for a hyperglycemic adult patient without hyperglycemic emergency or a previous diagnosis of diabetes?


Introduction

Emergency physicians are well versed in the management of acute diabetic emergencies such as hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). Aside from these emergent conditions, hyperglycemia in ED patients is frequently unrecognized, undertreated, and poorly communicated1. Thus, we may be missing an opportunity to positively impact our patients’ health, as early diagnosis and treatment of diabetes decreases long-term morbidity and improves outcomes2–4.

In 2018, 21.8% of all US adults who met laboratory criteria for diabetes were “not aware of or did not report having diabetes”5. ED patients are at particularly high risk for diabetes, and many adults that present to the ED meet American Diabetes Association (ADA) criteria for diabetes screening6–8. While screening for diabetes is not routine in the ED, random glucose levels are frequently obtained9. In ordering and interpreting the results of these tests, emergency physicians are optimally positioned to identify patients at high risk for diabetes and initiate treatment when indicated.


Does this hyperglycemic patient have a new diagnosis of diabetes?

After evaluating the patient for hyperglycemic emergencies, the ED clinician should focus on the distinction between type 1 and type 2 diabetes and the identification of complicating factors such as infection and dehydration.

History

  • Commonly, hyperglycemic patients present with polyuria, polydipsia, weight loss, and vision changes10.
  • Hyperglycemic patients require three separate assessments:
    • Evaluation for hyperglycemic emergencies (diabetic ketoacidosis and hyperglycemic hyperosmolar state)
    • Evaluation of the etiology for the hyperglycemia such as infection, ischemia (stroke, pulmonary embolism, acute coronary syndrome), medications (steroids), malignancy, and pregnancy.
    • Evaluation for type 1 versus type 2 diabetes.
      • Key elements of the history include duration of symptoms and personal or family history of diabetes or autoimmune disorders. A recent history of marked weight loss and other severe symptoms in a short period of time should raise suspicion for type 1 diabetes11.

 

Physical Exam

  • General Appearance: normal or thin body habitus should heighten suspicion for type 18.
  • Cardiovascular and mucous membranes: hyperglycemia related dehydration can result in dry mucous membranes and tachycardia.
  • Respiratory: tachypnea (suggestive of DKA) and signs of pulmonary infection
  • Neurologic: altered mentation (suggestive of HHS), and decreased sensation in the distal extremities (indicating neuropathy secondary to chronic hyperglycemia)
  • Skin: acanthosis nigricans, signs of infection, wounds on the feet, and decreased skin turgor

Laboratory Evaluation

Most patients with type 2 diabetes present without symptoms, and their hyperglycemia will be an incidental finding12. Symptomatic hyperglycemic patients may require an evaluation for electrolyte derangements, DKA, and hyperosmolarity with:

  • Point of care glucose
  • Basic metabolic panel
  • Complete blood count
  • Urinalysis
  • Urine pregnancy test for women of childbearing age
  • Venous blood gas
  • Serum osmolality
  • Beta-hydroxybutyrate

 

A new diagnosis of diabetes can be made in the ED using the ADA criteria. These criteria include8:

  • Random plasma glucose >200 mg/dL (11.1 mmol/L) AND classic symptoms of hyperglycemia or hyperglycemic crisis

OR two of the following abnormal test results:

  • Fasting plasma glucose >126 mg/dL (7.0 mmol/L)
  • A 2-hour plasma glucose >200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test
  • A1C >6.5%

ED Management

In ED patients without a hyperglycemic emergency in whom other dangerous etiologies have been excluded, the next step is to distinguish the type of diabetes. Patients with type 1 or autoimmune-mediated diabetes are at higher risk for poor short-term outcomes. Although type 1 diabetes is often thought of as a disease of adolescence, over 40% of patients with type 1 diabetes are diagnosed after 30 years of age13. Critically, failure to identify a patient with type 1 diabetes and initiate appropriate treatment can lead to rapid development of life-threatening hyperglycemic emergencies14.

Key Point: Have a high suspicion for type 1 diabetes in patients presenting with marked weight loss, ketonuria, a personal or family history of autoimmune disorders, and no family history of type 2 diabetes11.

Table 1. Clinical features at presentation that help to distinguish type 1 and type 2 diabetes (table reprinted from BMJ2020;370:m2998).8,15

Recommendations for treatment to specifically address uncomplicated hyperglycemia in the ED setting are limited14,21,22. Emergency Medicine (EM) physicians vary greatly in their thresholds for hyperglycemia management and comfort with initiation of outpatient treatment23. While there is evidence to suggest that discharge with elevated glucose does not result in short-term adverse events, this study does not adequately address safety in the subpopulation of newly diagnosed diabetics22. For patients with new-onset severe hyperglycemia (BG >300 mg/dL (16.7 mmol/L)), authors of this post suggest using a combination of IV fluids and a protocol similar to that studied by Magee et al, in which the patient is treated with rapid-acting insulin* in the emergency department and started on long term therapy from the ED24. This protocol was shown to be safe and showed improved glycemic control at 4 weeks24.

*Editor’s note: Insulin is not needed in all patients with suspected type 2 diabetes. The most important component is establishing rapid follow-up with a physician who can coordinate diabetes education and provide outpatient therapy. Discussing the patient with his/her primary care physician (if available) can assist, as the primary physician may want you to start a therapy such as metformin in suspected type 2 diabetes.  Of course, the patient’s social situation must be considered. For severe elevations and inability to follow up, admission may be required. Rapid acting insulin will only drop the blood glucose for several hours without other therapies, and then the patient is right back where they started.  Continue on for a great breakdown on disposition!


Disposition

Generally, the following categories can help determine disposition of the stable diabetic patient.

Category 1: If type 1 diabetes is suspected, consider either admission to the hospital for further evaluation or an ED endocrinology consult for assistance with discharge planning.

Category 2: Hyperglycemic patients with a clinical picture consistent with undiagnosed type 2 diabetes (i.e. obesity, family history of type 2 diabetes, dyslipidemia), without an apparent underlying cause of their hyperglycemia.

2A: Patients with asymptomatic, incidental hyperglycemia such as in case 1, do not meet ADA criteria for the diagnosis of diabetes8. However, these patients are very likely to be diagnosed with diabetes on confirmatory testing and should be directed to follow-up with a primary care provider (PCP) for further evaluation25. Currently, there is no minimum random plasma glucose level at which the ADA recommends screening for diabetes8. Studies evaluating random plasma glucose (RPG) as an independent predictor for undiagnosed diabetes found levels ranging from >100 mg/dL (5.6 mmol/L) to >155mg/dL (8.6 mmol/L) to be highly specific for undiagnosed diabetes25–28. As such, we suggest referring any patient with a random plasma glucose >126 mg/dL (7.0 mmol/L) for diabetes screening on outpatient follow-up24,27.

2B: Symptomatic patients with BG >200 mg/dL (11.1 mmol/L), such as in case 2, meet ADA criteria for the diagnosis of diabetes8. At the time of discharge, consider initiating metformin 500 mg once a day with the plan to increase to twice daily in one week12,29.  Metformin is usually well tolerated with minimal side effects, especially if taken with meals, but is contraindicated in patients with impaired renal function (eGFR <30 mL/min/1.73 m²), liver disease, active alcohol abuse, and unstable heart failure12,30. If prescriptions are provided, the patient will need close follow-up with endocrinology or their PCP for reassessment and ongoing medication adjustments.

2C: The disposition of patients with severe hyperglycemia (BG >300 mg/dL or 16.7mmol/L) varies widely based on practice environment and patient characteristics23. After initial resuscitation and ruling out hyperglycemic emergencies or an underlying cause, these patients are often stable for discharge. Most published guidelines focus on initiation of treatment in the outpatient setting but fail to address the management of severely hyperglycemic patients in the ED who are otherwise stable12,14,31,32.  To our knowledge, there is no consensus on initiation of anti-diabetes medications for patients with severe hyperglycemia in the ED14,22,24,31.

Patients with new-onset severe hyperglycemia with an unstable social situation or no access to follow-up care should be admitted for initiation of therapy29. In well-resourced settings with close follow-up and availability of diabetic education, there is limited evidence that shows both safety and efficacy with initiation of outpatient therapy on discharge from the ED21,24,33. As such, we believe it is reasonable to discharge a reliable patient with a plan for initiation of long-acting insulin therapy21,24.

Initiation of outpatient long-acting insulin therapy from the ED has several requirements to be successful:

  • Hospital (nursing, emergency department administration, endocrine, PCP) support
  • Availability of targeted patient education for safe administration of insulin and glucose monitoring
  • Availability of materials to provide the patient on discharge (glucometer and test strips)
  • Communication and coordination of care with outpatient providers

 

If the above requirements are met, consider starting long-acting insulin such as glargine 10 units daily or glargine 0.1-0.2 units/kg/day14,21,24. Patient education on the administration of insulin can be performed at the bedside with the assistance of training pens, visual aids, and video instructions34–37. If your institution has diabetes educators that provide training for hospitalized patients, consider asking for their assistance37. It may be beneficial to give the patient their first dose of long-acting insulin while still in the ED24. Consider the timing of administration of the long-acting insulin you give, as changing the timing of the dose will require careful attention.

When starting the patient on an insulin regimen, communication with the on-call endocrinologist or the patient’s PCP is crucial to enable coordination of care and close follow-up. The patient should also be discharged with a glucometer and other materials for glucose monitoring, with the plan to check their blood sugar at least twice per day24. The patient should be educated on the signs and symptoms of hypoglycemia and understand how to self-rescue should hypoglycemia occur21.


Take-Home Points

  • Type 1 (autoimmune) diabetes can present in adults.
  • Consider type 1 diabetes in adult patients with hyperglycemia and severe weight loss, polyuria, or polydipsia. This mandates an ED endocrinology consult or hospital admission.
  • For hyperglycemic, stable patients without concern for type 1 diabetes:
    • If asymptomatic with random BG >126 mg/dL (7.0 mmol/L), outpatient follow-up for diabetes screening is appropriate.
    • If symptomatic with a BG between 200 mg/dL (11.1 mmol/L) and 300 mg/dL (16.7 mmol/L), Metformin 500 mg once a day can be safely started in the ED and is usually well tolerated.
    • For severe hyperglycemia (BG >300 mg/dL or 16.7 mmol/L), the patient will likely require long-term insulin therapy. Disposition of these patients will vary by practice environment. Consider initiation of long-acting glargine at 0.1-0.2 units/kg/day on discharge for reliable patients in well-resourced settings with established hospital support.

Case Conclusions

Case 1: The patient is discharged home with primary care follow-up for further testing, as he is asymptomatic and does not meet ADA criteria for diagnosis of diabetes.

Case 2: The patient meets criteria for diagnosis of diabetes. After discussion with the patient’s primary care physician, he is discharged home on metformin 500 mg daily with follow-up.


References/Further Reading:

  1. Ginde AA, Savaser DJ, Camargo CA. Limited communication and management of emergency department hyperglycemia in hospitalized patients. J Hosp Med. 2009;4(1):45-49. doi:10.1002/jhm.400
  2. Bernard JB, Munoz C, Harper J, Muriello M, Rico E, Baldwin D. Treatment of inpatient hyperglycemia beginning in the emergency department: A randomized trial using insulins aspart and detemir compared with usual care. J Hosp Med. 2011;6(5):279-284. doi:10.1002/jhm.866
  3. Munoz C, Villanueva G, Fogg L, et al. Impact of a Subcutaneous Insulin Protocol in the Emergency Department: Rush Emergency Department Hyperglycemia Intervention (REDHI). J Emerg Med. 2011;40(5):493-498. doi:10.1016/j.jemermed.2008.03.017
  4. Colagiuri S, Cull CA, Holman RR. Are lower fasting plasma glucose levels at diagnosis of type 2 diabetes associated with improved outcomes? U.K. Prospective Diabetes Study 61. Diabetes Care. 2002;25(8):1410-1417. doi:http://dx.doi.org.ezproxy.uvm.edu/10.2337/diacare.25.8.1410
  5. National Diabetes Statistics Report 2020. Estimates of diabetes and its burden in the United States. Published online 2020:32.
  6. Ford W, Self WH, Slovis C, McNaughton CD. Diabetes in the Emergency Department and Hospital: Acute Care of Diabetes Patients. Curr Emerg Hosp Med Rep. 2013;1(1):1-9. doi:10.1007/s40138-012-0007-x
  7. Ginde AA, Delaney KE, Lieberman RM, Vanderweil SG, Camargo CA. Estimated Risk for Undiagnosed Diabetes in the Emergency Department: A Multicenter Survey. Acad Emerg Med. 2007;14(5):492-495. doi:https://doi.org/10.1111/j.1553-2712.2007.tb01815.x
  8. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021. 2021;44:19.
  9. National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables. Published online 2017:37.
  10. Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults – UpToDate. Accessed January 25, 2021. https://www.uptodate.com/contents/clinical-presentation-diagnosis-and-initial-evaluation-of-diabetes-mellitus-in-adults?search=diabetes&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
  11. Insulin therapy in type 2 diabetes mellitus – UpToDate. Accessed February 27, 2021. https://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?sectionName=Initial%20treatment&topicRef=1779&anchor=H674695863&source=see_link#H674695863
  12. Initial management of hyperglycemia in adults with type 2 diabetes mellitus – UpToDate. Accessed February 24, 2021. https://www.uptodate.com/contents/initial-management-of-hyperglycemia-in-adults-with-type-2-diabetes-mellitus?source=history_widget#H2640984997
  13. Thomas NJ, Jones SE, Weedon MN, Shields BM, Oram RA, Hattersley AT. Frequency and phenotype of type 1 diabetes in the first six decades of life: a cross-sectional, genetically stratified survival analysis from UK Biobank. Lancet Diabetes Endocrinol. 2018;6(2):122-129. doi:10.1016/S2213-8587(17)30362-5
  14. American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment. Diabetes Care. 2021;44(Supplement 1):S64-S74. doi:10.2337/dc17-S011
  15. Butler AE, Misselbrook D. Distinguishing between type 1 and type 2 diabetes. BMJ. 2020;370:m2998. doi:10.1136/bmj.m2998
  16. Barker JM. Clinical review: Type 1 diabetes-associated autoimmunity: natural history, genetic associations, and screening. J Clin Endocrinol Metab. 2006;91(4):1210-1217. doi:10.1210/jc.2005-1679
  17. Skyler JS, Bakris GL, Bonifacio E, et al. Differentiation of Diabetes by Pathophysiology, Natural History, and Prognosis. Diabetes. 2017;66(2):241-255. doi:10.2337/db16-0806
  18. Valdez R, Yoon PW, Liu T, Khoury MJ. Family history and prevalence of diabetes in the U.S. population: the 6-year results from the National Health and Nutrition Examination Survey (1999-2004). Diabetes Care. 2007;30(10):2517-2522. doi:10.2337/dc07-0720
  19. Ramtoola S, Nyeland ME, Jacobsen J, Ploug UJ, Kragh N, Zimmermann E. Characteristics of newly diagnosed adults with type 1 diabetes in the UK and evolution of glycaemic control, body mass index and Charlson comorbidity index over the first 5 years after diagnosis. Prim Care Diabetes. 2020;14(4):349-355. doi:10.1016/j.pcd.2019.09.009
  20. Shields BM, Peters JL, Cooper C, et al. Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature. BMJ Open. 2015;5(11):e009088. doi:10.1136/bmjopen-2015-009088
  21. Magee MF, Nassar CM, Copeland J, et al. Synergy to reduce emergency department visits for uncontrolled hyperglycemia. Diabetes Educ. 2013;39(3):354-364. doi:10.1177/0145721713484593
  22. Driver BE, Olives TD, Bischof JE, Salmen MR, Miner JR. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Ann Emerg Med. 2016;68(6):697-705.e3. doi:10.1016/j.annemergmed.2016.04.057
  23. Ginde AA, Delaney KE, Pallin DJ, Camargo CA. Multicenter Survey of Emergency Physician Management and Referral for Hyperglycemia. J Emerg Med. 2010;38(2):264-270. doi:10.1016/j.jemermed.2007.11.088
  24. Magee MF, Nassar CM, Mete M, White K, Youssef GA, Dubin JS. The Synergy To Enable Glycemic Control Following Emergency Department Discharge Program For Adults With Type 2 Diabetes: STEP-Diabetes. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2015;21(11):1227-1239. doi:10.4158/EP15655.OR
  25. Charfen MA, Ipp E, Kaji AH, Saleh T, Qazi MF, Lewis RJ. Detection of Undiagnosed Diabetes and Prediabetic States in High-risk Emergency Department Patients. Acad Emerg Med. 2009;16(5):394-402. doi:https://doi.org/10.1111/j.1553-2712.2009.00374.x
  26. Bowen ME, Xuan L, Lingvay I, Halm EA. Random Blood Glucose: A Robust Risk Factor For Type 2 Diabetes. J Clin Endocrinol Metab. 2015;100(4):1503-1510. doi:10.1210/jc.2014-4116
  27. Ziemer DC, Kolm P, Foster JK, et al. Random plasma glucose in serendipitous screening for glucose intolerance: screening for impaired glucose tolerance study 2. J Gen Intern Med. 2008;23(5):528-535. doi:10.1007/s11606-008-0524-1
  28. Ziemer DC, Kolm P, Weintraub WS, et al. Age, BMI, and race are less important than random plasma glucose in identifying risk of glucose intolerance: the Screening for Impaired Glucose Tolerance Study (SIGT 5). Diabetes Care. 2008;31(5):884-886. doi:10.2337/dc07-2282
  29. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2019.
  30. Metformin in the treatment of adults with type 2 diabetes mellitus – UpToDate. Accessed February 24, 2021. https://www.uptodate.com/contents/metformin-in-the-treatment-of-adults-with-type-2-diabetes-mellitus?sectionName=Contraindications&topicRef=1779&anchor=H56212110&source=see_link#H56212110
  31. Echouffo-Tcheugui JB, Garg R. Management of Hyperglycemia and Diabetes in the Emergency Department. Curr Diab Rep. 2017;17(8):56. doi:10.1007/s11892-017-0883-2
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  33. Babu A, Mehta A, Guerrero P, et al. Safe and Simple Emergency Department Discharge Therapy for Patients with Type 2 Diabetes Mellitus and Severe Hyperglycemia. Endocr Pract. 2009;15(7):696-704. doi:10.4158/EP09117.ORR
  34. Boston Medical Center. How to Inject Insulin with a Pen and Pen Needle.; 2019. Accessed April 21, 2021. https://www.youtube.com/watch?v=fJPzkzyuMZ8
  35. Mayo Clinic. How to Use an Insulin Pen – Mayo Clinic Patient Education.; 2014. Accessed April 21, 2021. https://www.youtube.com/watch?v=_fCqEIn7ccA
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  37. Lewis VR, Benda N, Nassar C, Magee M. Successful patient diabetes education in the emergency department. Diabetes Educ. 2015;41(3):343-350. doi:10.1177/0145721715577484

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