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Chronic hyperglycemia management

Chronic hyperglycemia management

Lifestyle changes. While there Performance feedback and analysis compelling evidence to Chronic hyperglycemia management hyperglycemja place for SGLT2i and Herbal fat-burning catalyst Hypegglycemia RA Herbal fat-burning catalyst in the Chroic of many people with type 2 diabetes based managemrnt their direct organ-protecting effects, it is acknowledged that to date these agents are expensive. GLP-1 receptor agonists are an alternative in patients with DKD as their glycemic effect is not related to eGFR. Hyperglycemia may be caused by: diabetes, various non-diabetic endocrine disorders insulin resistance and thyroid, adrenal, pancreatic, and pituitary disorderssepsis and certain infections, intracranial diseases e.

Chronic hyperglycemia management -

This releases a byproduct known as ketone. The body tries releasing ketones in the urine but cannot eliminate them. This causes a buildup in the blood, leading to ketoacidosis. Without treatment, DKA can lead to a diabetic coma.

Acute hyperglycemia needs urgent medical attention. In a hospital, doctors will typically replace fluids and electrolytes through an IV drip. They will then administer insulin to help manage the blood sugar.

A person should call or seek emergency treatment if they suspect they have acute hyperglycemia or DKA. If people notice their blood sugar levels frequently becoming elevated, they should consider discussing changes to their treatment and prevention plans. A doctor may adjust medications or suggest a higher dose of insulin.

They may also help the person develop a plan for what to do if their blood sugar levels spike suddenly. Acute hyperglycemia usually occurs in people living with type 2 diabetes and is when blood sugar levels suddenly increase.

It can cause potentially life threatening complications and typically requires emergency medical intervention. A person can take steps to help manage their blood sugar levels, such as following instructions on medications and insulin, regularly checking their blood sugar levels, living an active lifestyle, and following a suitable meal plan.

Treatment will typically involve replacing fluids and insulin. Hyperglycemia is a key feature of diabetes, which occurs when insulin does not process glucose effectively.

Triggers include a high carbohydrate…. People with diabetes can use various strategies to lower their blood sugar levels. The options include lifestyle and dietary changes and natural…. Hyperglycemia is a term for high blood sugar levels.

It can indicate diabetes and cause severe health problems without careful blood sugar management. An unusually high blood sugar reading can happen if a monitor is faulty or a person has an underlying health condition. Here, get some tips on…. Some animal products are a leading source of saturated fat in the diet.

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Medical News Today. Individual preferences and circumstances should inform the specific activity regimen. In addition to these activity minutes, breaking up sedentary time with activity breaks e.

A gradual increase in overall volume and intensity of activity does not require medical clearance Additional clinical assessment may be warranted in those with moderate-to-severe diabetic retinopathy, diabetic kidney disease, peripheral neuropathy, and unstable HF and for those prescribed insulin or with a history of hypoglycemia Individual preferences, motivations, and circumstances should inform choice.

Weight management should be a central focus for individuals with type 2 diabetes with overweight or obesity, with individualized weight loss goals.

Metabolic surgery, which is most effective when performed early during diabetes, can be considered in those without a sufficient response to nonsurgical weight loss interventions based on the specific context and preferences and should be accompanied by health behavior interventions.

The benefits of metabolic surgery need to be balanced against its potential adverse effects, which vary by procedure and include surgical complications, late metabolic or nutritional complications, and impact on psychological health 5 , 6 , People being considered for metabolic surgery should be evaluated for comorbid psychological conditions and social and situational circumstances that may interfere with surgery outcomes.

People who undergo metabolic surgery should receive long-term medical and behavioral support. Metabolic surgery should be performed in high-volume centers with experienced multidisciplinary teams SMART specific, measurable, attainable, relevant, time-based goals are more effective for achieving behavior change than nonspecific recommendations Self-monitoring of achievements e.

Behavioral health specialists or psychologists with specific training in behavior change interventions can be of particular value as members of the team to help the person with type 2 diabetes achieve goals.

Specific health behavior and weight management goals should be agreed on between the person with type 2 diabetes and the care team; shared decision-making is an important component of this discussion.

Emphasize self-monitoring behaviors and review data collected e. People taking insulin or a sulfonylurea should be educated about the risk, symptoms, and treatment of hypoglycemia when undertaking physical activity or adopting a specific nutritional plan; prescribe glucagon in people at risk for severe hypoglycemia.

DSMES and MNT can help the person living with diabetes to identify and address barriers to implementing healthier behaviors. The choice of glucose-lowering agents should be directed by the individual profile of the person with type 2 diabetes, in particular the presence of comorbidities, risk of side effects, preferences, and context Figs.

Pharmacological treatment of hyperglycemia must be integrated in DSMES and accompanied by a focus on healthy behaviors from diagnosis onwards. This should be integrated as part of a holistic, multifactorial approach to type 2 diabetes that includes weight, blood pressure, and lipid management Fig.

Whereas the pursuit of glycemic control and the pursuit of organ-specific e. Some agents, in particular SGLT2i, have been shown to protect organs heart, kidney partly independently of their glucose-lowering effect, as this organ protection also occurs in those not affected by type 2 diabetes.

Based on these principles, regardless of HbA 1c level or the presence of other glucose-lowering agents, all individuals with diabetes and established or subclinical CVD should be prescribed an agent with proven cardiovascular benefit from the GLP-1 RA class or SGLT2i class 5 , 6.

The evidence for cardiovascular benefits of GLP-1 RA and SGLT2i in those with only risk factors for CVD, based on MACE myocardial infarction, stroke, or cardiovascular death , is less robust, as fewer people with lower event rates are included in studies — Furthermore, it is important to recognize that the predicted absolute benefit of an intervention is dependent on the absolute risk, and thus those with prior CVD events are more likely to experience a benefit over intermediate time frames than those with cardiovascular risk factors only.

Likewise, those with HF HF with reduced ejection fraction or HF with preserved ejection fraction should receive an agent from the SGLT2i class with proven benefit for HF. In both instances, the goal of organ protection with SGLT2i or GLP-1 RA should be independent of background glucose-lowering therapies, current HbA 1c level, or target HbA 1c level Figs.

While there is compelling evidence to support a place for SGLT2i and the GLP-1 RA class in the treatment of many people with type 2 diabetes based on their direct organ-protecting effects, it is acknowledged that to date these agents are expensive.

In the setting of resource constraints, prioritization of the highest risk groups for access to these agents may be needed, with consideration of absolute risk reduction in addition to relative risk reductions. Evidence on specific agents and their effects on other comorbidities, such as NAFLD, is emerging.

There is emerging evidence for benefits of metabolic surgery and three classes of glucose-lowering therapy GLP-1 RA, SGLT2i, and GIP and GLP-1 RA , — , Overall, for treatment of hyperglycemia, metformin remains the agent of choice in most people with diabetes, based on its glucose-lowering efficacy, minimal risk of hypoglycemia, lack of weight increase, and affordability.

Often, monotherapy with metformin will not suffice to maintain glucose levels at target. As proposed in the previous consensus report and update 5 , 6 , other classes of agents are useful in combination with metformin or when metformin is contraindicated or not tolerated.

Selection of other glucose-lowering agents will be determined by the balance between the glucose-lowering efficacy and the side effect profile of the individual agents see Table 1. Special attention needs to be given to populations in which hypoglycemia is most dangerous, for example, people with frailty, in whom agents without risk of hypoglycemia need to be prioritized.

If sulfonylureas or insulin are used, consideration of less stringent targets in such settings is prudent and deprescribing if asymptomatic or severe hypoglycemia ensues. Finally, it needs to be stated that the evidence on organ-protecting or glucose-lowering effects of specific pharmacotherapies in specific subpopulations e.

This lack of evidence is, however, not a reason to withhold these medications in these subpopulations, given their proven benefits in large general populations.

Providers should continually update their knowledge on the efficacy and side effects of diabetes pharmacotherapy see Table 1. Assess the profile of the person with diabetes e.

Consider risk factors for medication adverse events e. Prioritize the use of organ-protective medications GLP-1 RA, SGLT2i, TZD in those with cardiorenal disease or NASH or at high risk. Reassessment of individual glycemic targets and their achievement at regular intervals is key Figs.

When targets are not met, in addition to addressing health behaviors and referral to DSMES, the intensification of glucose-lowering medication by combining agents with complementary mechanisms of action should be pursued. Traditionally, a stepwise approach was advocated, in which a new agent is added to the existing regimen, but evidence is growing to support a more proactive approach in many by combining glucose-lowering agents from initial diagnosis 6.

This presents the best opportunity to avoid complications of diabetes across the life span. Moreover, the pathophysiology of micro- and macrovascular damage shares more commonality than usually thought, suggesting that the prevention of microvascular disease may, in the long term, contribute to a reduction in macrovascular complications as well The knowledge base guiding clinicians beyond dual therapy in type 2 diabetes is still limited.

In general, intensification of treatment beyond two medications follows the same general principles as the addition of a second medication, with the assumption that the effectiveness of third and fourth medications will be generally less than when they are used alone.

Whereas solid evidence exists for combining SGLT2i and GLP-1 RA for weight and glucose lowering, emerging data suggest promise for combined effects on cardiorenal outcomes As more medications are added, there is an increased treatment burden and risk of adverse effects.

It is important to consider medication interactions and whether regimen complexity may become an obstacle to adherence. Fixed-dose combination preparations can improve medication-taking behaviors. Finally, with each additional medication comes increased costs, which can affect medication-taking behavior and medication effectiveness — Response to all therapies should be reviewed at regular intervals, including the impact on efficacy HbA 1c , weight , safety, and organ protection.

While most people with diabetes require intensification of glucose-lowering medications, some require medication reduction or discontinuation, particularly if the therapy is ineffective or associated with side effects such as hypoglycemia or when glycemic goals have changed because of a change in clinical circumstances e.

Medication should be stopped, or the dose reduced, if there are minimal benefits or if harm outweighs any benefit.

Consider initial combination therapy with glucose-lowering agents, especially in those with high HbA 1c at diagnosis i. When additional glycemic control is needed, incorporate, rather than substitute, glucose-lowering therapies with complementary mechanisms of action.

Consider deintensification of therapy, e. Insulin is a useful and effective glucose-lowering agent Fig. When glycemic measurements do not reach targets, and insulin is the best choice for the individual, its introduction should not be delayed.

When clinicians are not familiar with insulin use, referral to specialist care is indicated. GLP-1 RA should be considered in all when no contraindications are present before initiation of insulin therapy, as they allow lower glycemic targets to be reached with a lower injection burden and lower risk of hypoglycemia and weight gain than with insulin alone.

Place of insulin. CGM, continuous glucose monitoring; DSMES, diabetes self-management education and support; FPG, fasting plasma glucose; GLP-1 RA, glucagon-like peptide 1 receptor agonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T1D, type 1 diabetes; TIR, time in range.

The preferred way of initiating insulin in people with type 2 diabetes is to add basal insulin to the existing pharmacological therapy in conjunction with revisiting health behaviors and rereferral to DSMES. However, agents that cause hypoglycemia in themselves, such as sulfonylureas, should be discontinued once insulin is started.

Technologies allowing continuous monitoring of glucose levels without finger sticking have clear advantages in those on insulin. Other support tools and systems, such as apps guiding insulin dose adaptation or phone-based guidance, can also be helpful.

If affordable, basal insulin analog formulations are preferred to NPH insulin because of their reduced risk of hypoglycemia, particularly nocturnal hypoglycemia, when titrated to the same fasting glucose target Basal insulins are typically administered before bedtime, but, with newer analogs, more flexibility in the timing of insulin injection is possible i.

In some, as the disease progresses, despite titration of the basal insulin to correct fasting hyperglycemia typically more than 0. Mealtime insulin may be required to enhance postprandial blood glucose levels and achieve HbA 1c targets. A straightforward way to introduce mealtime insulin is to start with a short- or rapid-acting insulin injection before the meal associated with the largest glucose excursion.

Adding mealtime rapid-acting insulin requires increased DSMES and self-monitoring of glucose levels and adds complexity and cost to the therapy.

In contrast to basal insulin analogs, the evidence supporting the choice of mealtime rapid-acting insulin analogs is less clear Another simpler and still popular way of combining mealtime and basal insulin components is using premixed insulins.

Insulin analog-based combinations have the advantage of resulting in fewer hypoglycemic events and weight gain than are typically observed with human premixed insulin Finally, it needs to be reemphasized that, in all insulin-treated people with type 2 diabetes, agents associated with cardiorenal protection or weight reduction should be kept in the treatment regimen whenever possible The combination of a basal insulin analog and GLP-1 RA in one injection may be a simple way to reduce the burden and complexity of treatment The use of a GLP-1 RA should be considered prior to initiation of insulin.

When initiating insulin, start with a basal insulin and intensify the dose in a timely fashion, titrating to achieve an individualized fasting glycemic target set for every person. The use of technology in the therapy of people with type 2 diabetes is increasing through a broad range of approaches, for example, telehealth, remote monitoring systems, CGM, and behavioral aids to support physical activity, meal planning and monitoring, medication-taking behavior, mindfulness, and stress management.

Evidence on the impact of these systems is variable and highly dependent on the embedding of the technology in a more comprehensive approach. Evidence for a beneficial impact of telehealth on achieving treatment goals in those living with type 2 diabetes is growing , During the COVID pandemic, telehealth has proven to be an efficient way of overseeing the treatment of people with type 2 diabetes.

In particular, interventions using apps as tools to support DSMES have been shown to have an impact on outcomes For those needing insulin as part of their treatment, smart insulin pens and insulin pumps continuous subcutaneous insulin infusion [CSII] are available.

Specific evidence on the benefit of smart pens in people with type 2 diabetes is still scarce. CSII use is associated with small improvements in HbA 1c and fewer hypoglycemic events, suggesting that CSII can be considered in people living with type 2 diabetes treated with multiple daily insulin injections and able to manage the device Again, for optimal effect, this technology should be embedded in an integrated approach to type 2 diabetes therapy, specifically to avoid weight gain In individuals with type 2 diabetes treated with insulin, CGM, both intermittently scanned CGM and real-time CGM, has gained traction, with evidence that CGM results in better overall glucose control as defined by HbA 1c and time in range 3.

As with other wearables, for example, those collecting steps walked or monitoring dietary intake, medication dose administered, or sleep quality, use of CGM has also been proposed as a motivational tool for those with type 2 diabetes not on insulin therapy, but the evidence on this is modest Finally, to date, no convincing evidence is available on the use of hybrid closed-loop systems specifically in people with type 2 diabetes.

Technology can be useful in people with type 2 diabetes but needs to be part of a holistic plan of care and supported by DSMES.

We are fortunate to have evidence on numerous effective interventions in type 2 diabetes, but translating this evidence into practice cannot rest only with front-line clinicians during individual clinic visits.

The systems of care that support front-line clinicians have a significant role in improving diabetes clinical management, outcomes, and experience for people living with diabetes.

Front-line clinicians must inform and drive the design of care, but the systems of care should be held accountable for implementation. Supplementary Table 2 , informed by the Effective Practice and Organization of Care EPOC taxonomy , outlines key domains and questions that must be answered to achieve the goal of better care and outcomes for people living with type 2 diabetes.

All levels of the care delivery system have a role and responsibility in improving diabetes management. Clinic leaders have a responsibility to improve workflows to make it easy to provide evidence-based care and provide data to inform quality improvement efforts.

Continuing education is necessary to ensure evolving evidence reaches people living with type 2 diabetes. Policy makers have a responsibility to ensure that evidence-based interventions are available and affordable to all.

Interventions to improve diabetes must also include the health system including the microsystems within a system and governmental agencies. Policy makers, together with all stakeholders, should reflect on care delivery.

How, where, and by whom is care delivered? Who coordinates care and the management of care processes? Practices and systems must establish enhanced communication technology to improve engagement. Governance arrangements must be implemented specifically around accountability for health professionals, with a focus on training and evaluation of quality of practice.

Finally, reflection is needed around implementation strategies at the level of the system, facility, and individual health care workers. These principles are aligned with recommendations outlined in the recent Lancet Commission on diabetes Identify and incorporate continuing education activities on the management of type 2 diabetes for all members of the health care team.

Team-based care is required for integrated care of diabetes; this includes coordination between multiple disciplines diabetes care and education specialist, dietitians, psychologists, etc.

and often other medical specialties primary care, endocrinology, ophthalmology, nephrology, etc. Management of type 2 diabetes requires continuous quality improvement interventions tailored to the local setting. In this th year since the discovery and partial purification of insulin, we should remember the remarkable speed at which this first glucose-lowering medication was developed and distributed as life-saving therapy for people with diabetes.

Through our experience in the last few years with the COVID pandemic, we have demonstrated how quickly many governments, industry, health care systems, and academic institutions can respond to global health care crises.

Within a year of identification of the severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 virus, preventive and therapeutic products were not only developed and tested but also administered on a massive scale.

The annual global mortality rate directly attributable to diabetes is approximately 1. Although not as spectacular as the impact of COVID on the health of society, diabetes is sure and steady in its burden, increasing in prevalence and with an increase in mortality and morbidity over time.

Two centuries of investigation into the pathophysiology of diabetes have led to the extraordinary advances in treatment of the last two decades. As reviewed in this consensus report, encouraging healthy behaviors, DSMES, medications, devices, technologies, and organization of care all represent effective tools for the management of diabetes to reduce its morbidity and mortality.

However, despite the generous approach of Banting and Best in licensing the patent for insulin for one Canadian dollar, it is not yet readily available to all people with diabetes , Recent events have focused attention on the contribution of social determinants of health and a lack of equity in the delivery of care to disparate and unfavorable outcomes.

Today, the major opportunities to improve diabetes outcomes in the near term come from more effective implementation of best evidence through organization of care at all levels national to individual practices and from addressing social determinants of health.

Every reader of this consensus report has a role to play in better implementation with a focus on equity. For providers, that could involve a focus on shared decision-making to improve adherence to behavioral and medication interventions as well as organizing practice to minimize therapeutic inertia and enhance engagement and support for all people with diabetes.

For policy makers, health care systems, payors, and companies with marketed products or services, ensuring equitable access to minimize health disparities should be a priority.

Broad support for basic science is necessary to bring about the next generation of interventions. Precision medicine initiatives, whether omics-based or focused on social determinants of health, aim to optimally target interventions based on the wide heterogeneity of the population affected by diabetes.

Precision medicine has tremendous but largely unrealized promise. When these efforts are driven by real-world data, causal inference study design and analysis create greater confidence in the implementation and evaluation of insights.

Studies should be conducted to support the better understanding of precision medicine approaches to the full spectrum of diabetes interventions, from medications to behavioral treatments and diabetes support.

Several key areas where further research could better inform future consensus reports were of particular interest to the writing group. For each area, one could add the need for more precision medicine insights and a better understanding of the full spectrum of investigations that are supporting efforts to advance the field from basic to implementation science.

Regulatory reform, more efficient study conduct and analysis, coordinated global efforts in defining outcomes and data collection instruments, data sharing, exploration of new forms of health care delivery e.

Study conduct. Across the spectrum from highly controlled trials to observational studies, paying greater attention to subgroups, in particular vulnerable populations, is essential.

Dedicated studies in young adults with type 2 diabetes, or including much larger numbers of younger adults in broader studies, are essential to better understand how to mitigate their high risk of early disability.

As more younger adults are being treated with therapies that have been inadequately studied in pregnancy, it is essential to describe the reproductive safety of recommended approaches.

Sex balance is another dimension where our present studies fail to be representative. Weight management. With the emergence of more effective behavioral and medical therapies and novel surgical approaches for the treatment of people who are overweight with diabetes, more direct comparisons are required to better target interventions based on impact and cost-effectiveness.

Studies designed to explicitly examine glucose-centric versus weight-centric approaches to diabetes management are needed. The impact of prioritizing early aggressive therapy to induce remission is unclear. Cardiorenal protection. As discussed, there is considerable uncertainty about the absolute benefits of GLP-1 RA and SGLT2i for CVD outcomes in those with risk factors only.

As all people with diabetes are at high risk of CVD, HF, and CKD over time, real-world evidence and cost-effectiveness studies of GLP-1 RA and SGLT2i in broad populations would help to better target interventions to have the greatest impact on outcomes.

Glucose monitoring. There are numerous studies underway to understand the role of interventions in the setting of NAFLD and cognitive impairment. NAFLD is highly prevalent, and thus understanding the impact of interventions on person-centered outcomes and costs is essential.

Cognitive impairment is a major burden to people with diabetes, their families, and society; better understanding of the pathophysiology and the impact of interventions is a challenging but high-reward area for investigation.

There are virtually no data to inform best practice in the care of people with diabetes and advanced CKD, particularly in dialysis-dependent kidney disease. Additional studies, particularly of GLP-1 RA, GIP and GLP-1 RA, and SGLT2i, will hopefully provide new avenues to reduce mortality in this population, in which there are enormous health disparities.

Screening and prevention. Screening for diabetes and its complications and comorbidities remains inadequate. Early intervention to prevent progression is also generally suboptimal.

National health care systems should comprehensively assess the implementation of recommendations and create incentives for effective programs. To optimally target resources, additional studies may be required on natural history and subpopulations, as much of the rationale for screening is based on studies conducted decades ago.

Remote care, wearables, apps, and decision support aids have exploded in availability, and a clear rationale exists as to why they may be of benefit. However, their optimal application is poorly understood. Sleep and chronotype. Poor sleep is common and clearly associated with poor outcomes.

Further studies are needed to understand behavioral sleep therapy and its benefits more fully as well as the benefits of medication and device aids. As chronotype is potentially modifiable, future research should focus on social and lifestyle factors to optimize interventional responses.

Until science and medicine bring us further insights, we recommend empathic, person-centered decision-making and support informed by an understanding of local resources and individual social determinants of health.

Combined with consistent efforts to improve health behaviors nutrition, activity, sleep, and self-monitoring and to provide DSMES, these form the foundation of diabetes management. In this context, acceptance of, adherence to, and persistence with medical and behavioral interventions to support cardiorenal health, cardiovascular risk reduction, and attainment of glycemic and weight goals will prevent complications and optimize quality of life.

We must establish and refine quality improvement efforts in diabetes care at the local level to equitably implement evidence-based interventions for the benefit of all people with type 2 diabetes.

and J. were co-chairs for the Consensus Report Writing Group. were the writing group members for ADA. were the writing group members for EASD. The article was reviewed for EASD by its Committee on Clinical Affairs and approved by its Executive Board.

The article was reviewed for ADA by its Professional Practice Committee. Zaccardi performed the literature searches and M. Bonar, C. Franklin, and S. Jamal assisted with the conception and execution of figures and tables; T.

Yates and J. Henson supported the production and content of Fig. Karagiannis Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece assisted in the credibility assessment and interpretation of meta-analyses evaluating the effects of glucose-lowering medications across subgroup populations and contributed in applying GRADE guidance in the formulation of respective practice recommendations.

Bradley Ohio State University College of Medicine, Columbus, OH , P. Home Newcastle University, Newcastle, U. Kirkman University of North Carolina, Chapel Hill, NC , S. Dinneen Galway University Hospitals, Galway, Ireland , H.

Rodbard Adventis HealthCare Shady Grove Medical Center, Rockville, MD , G. Sesti Sapienza University of Rome, Rome, Italy , P.

Newland-Jones University of Southampton, Southampton, U. Montanya University of Barcelona, Barcelona, Spain , and M. Nauck Medical Department I, St.

Josef-Hospital [Ruhr-University Bochum], Bochum, Germany all served as invited reviewers. We acknowledge the support of N. El Sayed, R. Bannuru, M. Saraco, and M. Hill all ADA, Arlington, VA , P.

Niemann and N. Buckley-Mühge both EASD, Dusseldorf, Germany , the Committee for Clinical Affairs of the EASD, and the Professional Practice Committee of the ADA. Data Availability. This activity was funded by the American Diabetes Association and the European Association for the Study of Diabetes.

Duality of Interest. has acted as a consultant, advisory board member, and speaker for Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Sanofi, an advisory board member and speaker for AstraZeneca, an advisory board member for Janssen, Lexicon, Pfizer, and ShouTi Pharma, and as a speaker for Napp Pharmaceuticals, Novartis, and Takeda Pharmaceuticals International.

Her institution has received grants from Novo Nordisk, Sanofi, Eli Lilly, Boehringer Ingelheim, AstraZeneca, and Janssen. has served as a consultant for Applied Therapeutics, Duke, Fractyl, Novo Nordisk, Pfizer, and Sanofi. is a nominating work group member of the American Academy of Physician Assistants.

is an advisor to Vida and Lark. is under a license agreement between Johns Hopkins HealthCare Solutions and Johns Hopkins University. She and the university are entitled to royalty distributions related to an online diabetes prevention program.

participated in at least one advisory board for Bayer, Traverse, and AstraZeneca. Her employer receives industry research support from Bayer and Astra Zeneca.

is a member of the advisory board for Abbott, Applied Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Hengrui Pharmaceuticals, Menarini International, Novo Nordisk, Sanofi, and Vertex.

His employer receives research funding from AstraZeneca and Boheringer Ingelheim. serves or has served on the advisory panel for Novo Nordisk, Sanofi, MSD, Eli Lilly, Novartis, AstraZeneca, Boehringer Ingelheim, Roche, Medtronic, ActoBio Therapeutics, Pfizer, Insulet, and Zealand Pharma.

Financial compensation for these activities has been received by KU Leuven. KU Leuven has received research support for C. from Medtronic, Novo Nordisk, Sanofi, and ActoBio Therapeutics.

is a consultant to Novo Nordisk, Fractyl, Recor, Keyron, and Metadeq and is on the scientific board of Fractyl. Her institution has also received consultancy fees from AstraZeneca, Bayer, Boehringer Ingelheim, Novo Nordisk, Gilead, and MSD and lecture fees from Sanofi, Astellas, Novo Nordisk, Bayer, and AstraZeneca.

has served on the advisory board for Novo Nordisk and Boehringer Ingelheim, and his university has received research funding.

His university also receives funding for educational and research support from Eli Lilly. is a paid consultant to Anji Pharmaceuticals, Boehringer Ingelheim, Eli Lilly, Fortress Biotech, Janssen, Mellitus Health, Moderna, Pendulum Therapeutics, Praetego, ReachMD, Stability Health, and Zealand Pharma.

He is a member of the advisory board for Boehringer Ingelheim, Eli Lilly, Mellitus Health, Moderna, Novo Nordisk, Pendulum Therapeutics, Praetego, Stability Health, vTv Therapeutics, and Zealand Pharma.

His employer receives research funding from Dexcom, Eli Lilly, NovaTarg, Novo Nordisk, Sanofi, Tolerion, and vTv Therapeutics. He is an investor in Mellitus Health, Pendulum Therapeutics, and PhaseBio.

Author Contributions. All authors were responsible for drafting the article and revising it critically for important intellectual content.

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Volume 45, Issue Previous Article Next Article. Data Sources, Searches, and Study Selection. The Rationale, Importance, and Context of Glucose-Lowering Treatment. Principles of Care. Personalized Approach to Treatment Based on Individual Characteristics and Comorbidities: Recommended Process for Glucose-Lowering Medication Selection.

Obesity and Weight-Related Comorbidities, Particularly Nafld and Nash. Putting It All Together: Strategies for Implementation. Article Information. Article Navigation. Consensus Report September 28 Management of Hyperglycemia in Type 2 Diabetes, Typically, replacement volumes are 1, mL in the first hour 15 to 30 mL per kg per hour , 1, mL in the second and possibly third hours, and to mL in the fourth hour and possibly beyond.

For the physician, the key to fluid management is vigilant monitoring and adjustment of response on a continuous basis. Volume replacement is critical in determining survival and in correcting hyperglycemic hyperosmolarity.

One study 12 of patients with diabetic ketoacidosis documented that hydration alone without any insulin administration reduced hyperglycemia, hyperosmolarity, acidosis and insulin counterregulatory hormone levels. Generally, however, insulin is also administered.

Guidelines for fluid replacement in hyperglycemic hyperosmolarity are provided in Table 2. Early in treatment, a decrease in the plasma glucose level serves as an index of the adequacy of rehydration and the restoration of renal perfusion. Failure of the plasma glucose level to decline by 75 to mg per dL 4.

The physician must be wary of uncontrolled diabetes in patients with renal failure. These patients may present with marked hyperglycemia and elevated BUN and creatinine levels. If renal failure is not recognized and rapid fluid replacement is instituted, the likely consequences are congestive heart failure and pulmonary edema.

In patients with hyperglycemia and renal failure, insulin administration may be all that is necessary. Insulin reduces elevated serum potassium levels. As the glucose level falls, water freed from its osmotic hold moves out of the extracellular fluid into the intracellular space intracellular fluid , thereby decreasing the manifestations of circulatory congestion.

Sudden loss of diabetic control in the presence of renal failure may cause pulmonary edema and life-threatening hyperkalemia.

Both of these conditions can be reversed by insulin alone. Electrolyte deficits in patients with uncontrolled diabetes are in the following ranges: sodium, 7 to 13 mEq per kg; chloride, 3 to 7 mEq per kg; potassium, 5 to 15 mEq per kg; phosphate as phosphorus , 70 to mmol; calcium, 50 to mEq; and magnesium, 50 to mEq.

A variety of physiologic multielectrolyte solutions e. Loss of sodium occurs because of osmotic diuresis and the absence of insulin, which is essential for distal tubular sodium reabsorption.

Because sodium losses are proportionally less than water losses, hypernatremia may occur. In the absence of insulin, glucose is largely confined to the extracellular fluid compartment. The osmotic action of glucose causes water to flow out of the intra-cellular fluid into the extracellular fluid compartment, with consequent dilution of extra-cellular sodium.

One group of investigators 17 demonstrated that the measured serum sodium concentration in the presence of hyperglycemia may be corrected by adding 2.

Total body potassium depletion is the rule in uncontrolled diabetes and related chronic catabolic states e. As with phosphate and magnesium, the degree of total body potassium depletion is often unrecognized or underestimated because of the initially elevated serum concentrations until correction of the underlying catabolic state is undertaken.

At this time, as potassium returns to its intracellular site along with magnesium and phosphate under the influence of insulin and renewed protein synthesis, the deficiency may become chemically and, occasionally, clinically overt unless supplements are administered during the early phases of therapy.

Recommendations for potassium administration in adults are provided in Table 2. The use of potassium acetate, potassium phosphate or a mixture of the two avoids administration of excess chloride.

The objective of potassium replacement is to maintain normokalemia. The total body deficits of potassium cannot and should not be replaced acutely. Full correction of the potassium level requires days to weeks of steady anabolism.

Even in the presence of renal insufficiency, early potassium replacement may be indicated because, with the exception of urinary loss, all other factors that drive the serum potassium level down in the treated patient are occurring.

Caution must be exercised in patients with diabetic nephropathy who may have renal tubular acidosis associated with hyperaldosteronism and hyporeninemia and resultant hyperkalemia. Once insulin is administered, potassium moves intracellularly because of either insulin stimulation of sodium-potassium adenosine triphosphatase or insulin-induced synthesis of phosphate esters intracellularly.

These anions attract potassium into the cells. Thus, to replace intracellular losses, potassium should be given with an anion that distributes in the intracellular fluid i. The benefits and risks of phosphate repletion in patients with uncontrolled diabetes have been investigated primarily in patients with acute diabetic ketoacidosis.

Chronic catabolic states, including hyperosmolar diabetes, are likely to be associated with more severe total body phosphate depletion and its unmasking during treatment, as originally noted in the refeeding syndrome.

Although phosphate replacement makes physiologic sense, no controlled data demonstrate that it alters the outcome or contributes to survival in patients with uncontrolled diabetes unless severe reductions in the serum phosphate level i.

The only risk of giving phosphate is the occasional development of hypocalcemic tetany described in diabetic ketoacidosis, 22 but this condition does not occur when magnesium is supplemented. As many as 40 percent of outpatients with diabetes and 90 percent of patients with uncontrolled diabetes after 12 hours of therapy are hypomagnesemic.

These manifestations include ECG changes, arrhythmias, muscle weakness, convulsions, stupor, confusion and agitation. As is true of the serum potassium level, the serum magnesium concentration is an unreliable marker of total body stores of this predominantly intracellular cation.

Many patients have elevated serum magnesium levels on presentation, and hypomagnesemia may not be evident for hours. Serum magnesium levels and body stores parallel and mirror those of potassium in hyperosmolar hyperglycemic syndrome.

Unless precluded by renal failure of hypermagnesemia, the routine administration of magnesium to patients with uncontrolled diabetes is safe and physiologically appropriate. Because many patients with diabetes and hyperosmolar hyperglycemic syndrome fit the criteria for catabolic malnourishment, they are at risk for development of the refeeding syndrome.

Concern, primarily focused on the potential for cerebral edema, has been expressed about the effects of rapid fluid administration, the use of hypotonic fluids to treat hyperglycemic hyperosmolarity and the dangers of rapid reduction of the effective osmolarity to mOsm per L or the glucose level to to mg per dL Cerebral edema occurs almost exclusively in young patients who have nonhyperosmolar diabetes with diabetic ketoacidosis.

This complication is exceedingly rare in adult patients with hyperosmolar hyperglycemic syndrome. In the United States, diabetic ketoacidosis and hyperosmolar diabetes are responsible for thousands of deaths every year, whereas fatal cerebral edema in adults almost never occurs.

Many more patients with uncontrolled diabetes die as a result of undertreatment than overtreatment. Any recommendation to reduce the rate of correction of hyperglycemia risks increasing the mortality rate and should be viewed with alarm. Rapid correction of hyperosmolarity to an effective osmolarity of mOsm per L and the plasma glucose level to to mg per dL Thereafter, a much slower rate of correction toward normal is warranted.

Insulin has a direct antinatriuretic effect on the kidney. Vascular occlusions i. With aggressive rehydration, the incidence of these complications may be reduced to 2 percent.

Improving the management results for hyperosmolar hyperglycemic syndrome requires an effective preventive strategy.

Patients with hyperosmolar diabetes tend to be elderly and to have type 2 diabetes. Often, these patients live alone, and social isolation is a precipitant in one third to one half of hyperosmolar diabetes episodes.

If the patient displays any change in mental status or symptoms of loss of diabetic control, this person is instructed to contact the patient's physician immediately.

Nursing home residents are prone to develop dehydration, hyperosmolarity and hyperglycemia. Thus, education of nursing home staff in the prevention and detection of diabetes-related problems is also essential.

Fishbein H, Palumbo PJ. Acute metabolic complications in diabetes.

The treatment of Herbal fat-burning catalyst depends on a Crhonic of factors, including how ,anagement and how Meal timing for optimal performance you have attacks and how Training nutrition your Chronic hyperglycemia management is. Hyyperglycemia age, overall Chronic hyperglycemia management, and mwnagement function are also important. The American Diabetes Association ADA stresses Janagement each person with diabetes should have a personalized treatment plan. While the ADA offers an algorithm to help determine the right medication for certain situations, decisions should ultimately be made on an individual basis. This article explains things you can do to treat hyperglycemia at home, medications that may be used, and signs that you might need to contact your healthcare provider. Lifestyle management is the most critical factor in treating hyperglycemia. The keys to lifestyle modification are to get support and be consistent. Hyperglycemia is the technical Managemenf for high blood glucose Muscle mass preservation sugar. High Chrnic glucose happens when the body has too little insulin or when the Herbal fat-burning catalyst can't use insulin properly. Part of managing your diabetes is checking your blood glucose often. Ask your doctor how often you should check and what your glucose sugar levels should be. Checking your blood and then treating high blood glucose early will help you avoid problems associated with hyperglycemia. Chronic hyperglycemia management

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