This protocol applies to adults with type 2 diabetes who present with measurable signs of severe hyperglycemia — whether symptomatic or detected through laboratory values — and guides initial management in this clinically urgent scenario.
Patients in this group have symptoms of hyperglycemia (e.g., polyuria or polydipsia), or a Hemoglobin A1C above 10% (>86 mmol/mol), or blood glucose at or above 300 mg/dL (≥16.7 mmol/L). Catabolic features — including weight loss, hypertriglyceridemia, or ketosis — may also be present and are clinically significant in selecting the initial approach.
In this setting, injectable therapy is a central consideration from the outset. The presence of catabolic features further informs whether and how such therapy should be initiated. Combination strategies may be incorporated to address glycemic control alongside other clinical outcomes. The complete algorithm, full range of options, and sequencing logic are detailed in the protocol.
Treatment goal: Resolution of glucose toxicity and severe hyperglycemia (blood glucose below 300 mg/dL), after which the medication plan can be simplified or transitioned to other agents.
DOI: 10.2337/dc26-S009
In adults with type 2 diabetes, initiation of insulin should be considered regardless of background glucose-lowering therapy or disease duration if symptoms of hyperglycemia are present or when A1C or blood glucose levels are very high (i.e., A1C >10% [>86 mmol/mol] or blood glucose ≥300 mg/dL [≥16.7 mmol/L]).
It is common practice to initiate insulin therapy for people who present with blood glucose levels ≥300 mg/dL (≥16.7 mmol/L) or A1C >10% (>86 mmol/mol) or if the individual has symptoms of hyperglycemia (i.e., polyuria or polydipsia) or evidence of catabolism (unexpected weight loss).
If insulin is used, combination therapy with a GLP-1 RA, including a dual GIP and GLP-1 RA, is recommended for greater glycemic effectiveness as well as beneficial effects on weight and hypoglycemia risk for adults with type 2 diabetes.
Insulin should be considered as part of any combination medication plan when hyperglycemia is severe, especially if catabolic features (weight loss, hypertriglyceridemia, and ketosis) are present.
As glucose toxicity resolves, simplifying the medication plan and/or changing to noninsulin agents is possible.
View source ↗