Normally, the body uses a hormone called insulin to move glucose from the blood into cells, thereby lowering glucose in the blood and providing cells with energy.

Hyperglycemia can occur when the body does not produce enough insulin or does not respond to insulin correctly. In both cases, glucose stays in the blood instead of being sent to the cells, and as a result, blood glucose levels remain elevated.

If more glucose enters the bloodstream—if you eat carbohydrate-rich food, for example—the blood glucose levels climb even higher. In some cases, people with diabetes who have hyperglycemia can develop a complication called diabetic ketoacidosis DKA.

In this condition, the cells cannot access glucose. Instead, the body gets energy by breaking down fats. This process produces compounds called ketones, which build up in the blood, causing it to become acidic. DKA is a life-threatening condition. DKA is most commonly associated with type 1 diabetes , but can occur in people with type 2 as well.

In people with type 2 diabetes , very high blood glucose levels can lead to a life-threatening condition called hyperosmolar hyperglycemic state HHS , which causes profound dehydration and a change in mental status.

Hyperglycemia most commonly affects people who have diabetes. In type 1 diabetes, the body does not make enough insulin.

In type 2 diabetes, the body makes an adequate amount of insulin, but the cells do not respond to it properly. This is called insulin resistance. A diagnosis of hyperglycemia usually involves a review of your medical history, a physical exam, and blood tests.

The doctor will ask about your symptoms and whether you have a family history of diabetes or other risk factors associated with hyperglycemia. He or she will conduct a physical exam. Ultimately, though, blood tests that measure blood glucose levels are necessary to definitively diagnose hyperglycemia.

Other blood tests may include a hemoglobin A1C test also known as glycated hemoglobin test and an oral glucose tolerance test OGTT. The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since and last updated in The target audience is the full spectrum of the professional health care team providing diabetes care in the U.

and Europe. A systematic examination of publications since informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep.

There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium—glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease.

After a summary listing of consensus recommendations, practical tips for implementation are provided. Type 2 diabetes is a chronic complex disease, and management requires multifactorial behavioral and pharmacological treatments to prevent or delay complications and maintain quality of life Fig.

This includes management of blood glucose levels, weight, cardiovascular risk factors, comorbidities, and complications. This necessitates that care be delivered in an organized and structured way, such as described in the chronic care model, and includes a person-centered approach to enhance engagement in self-care activities 1.

Careful consideration of social determinants of health and the preferences of people living with diabetes must inform individualization of treatment goals and strategies 2.

Decision cycle for person-centered glycemic management in type 2 diabetes. Adapted from Davies et al. BGM, blood glucose monitoring; BP, blood pressure; CGM, continuous glucose monitoring; CKD, chronic kidney disease; CVD, atherosclerotic cardiovascular disease; DSMES, diabetes self-management education and support; HF, heart failure.

This consensus report addresses the approaches to management of blood glucose levels in nonpregnant adults with type 2 diabetes. The principles and approach for achieving this are summarized in Fig. These recommendations are not generally applicable to individuals with diabetes due to other causes, for example, monogenic diabetes, secondary diabetes, and type 1 diabetes, or to children.

The writing group members were appointed by the American Diabetes Association ADA and European Association for the Study of Diabetes EASD. The group largely worked virtually, with regular teleconferences from September , a 3-day workshop in January , and a face-to-face 2-day meeting in April The writing group accepted the 3 , 4 , 5 , and 6 editions of this consensus report as a starting point.

To identify newer evidence, a search was conducted on PubMed for randomized control trials RCTs , systematic reviews, and meta-analyses published in English between 28 January and 13 June ; eligible publications examined the effectiveness or safety of pharmacological or nonpharmacological interventions in adults with type 2 diabetes.

Reference lists in eligible reports were scanned to identify additional relevant articles. Papers were grouped according to subject, and the authors reviewed this new evidence. Up-to-date meta-analyses evaluating the effects of therapeutic interventions across clinically important subgroup populations were assessed in terms of their credibility using relevant guidance 7 , 8.

Evidence appraisal was informed by the Grading of Recommendations Assessment, Development and Evaluation GRADE guidelines on the formulation of clinical practice recommendations 9 , The draft consensus recommendations were evaluated by invited reviewers and presented for public comment.

Suggestions were incorporated as deemed appropriate by the authors see Acknowledgments. Nevertheless, although evidence based with stakeholder input, the recommendations presented herein reflect the values and preferences of the consensus group. This is often delivered in the context of diabetes self-management education and support DSMES.

The expanding number of glucose-lowering interventions—from behavioral interventions to pharmacological interventions, devices, and surgery—and growing information about their benefits and risks provide more options for people with diabetes and providers but complicate decision-making.

The demonstrated benefits for high-risk individuals with atherosclerotic cardiovascular disease CVD , heart failure HF , or chronic kidney disease CKD afforded by the glucagon-like peptide 1 receptor agonists GLP-1 RA and sodium—glucose cotransporter 2 inhibitors SGLT2i provide important progress in treatment aimed at reducing the progression and burden of diabetes and its complications.

These benefits are largely independent of their glucose-lowering effects. These treatments were initially introduced as glucose-lowering agents but are now also prescribed for organ protection.

In this consensus report, we summarize a large body of recent evidence for practitioners in the U. and Europe with the aim of simplifying clinical decision-making and focusing our efforts on providing holistic person-centered care. Attaining recommended glycemic targets yields substantial and enduring reductions in the onset and progression of microvascular complications 11 , 12 , and early intervention is essential The greatest absolute risk reduction comes from improving very elevated glycemic levels, and a more modest reduction results from near normalization of plasma glucose levels 2 , The impact of glucose control on macrovascular complications is less certain but is supported by multiple meta-analyses and epidemiological studies.

Because the benefits of intensive glucose control emerge slowly while the harms can be immediate, people with longer life expectancy have more to gain from early intensive glycemic management. Aiming for a lower HbA 1c level than this may have value if it can be achieved safely without significant hypoglycemia or other adverse treatment effects.

A lower target may be reasonable, particularly when using pharmacological agents that are not associated with hypoglycemic risk. Higher targets can be appropriate in cases of limited life expectancy, advanced complications, or poor tolerability or if other factors such as frailty are present.

Communication between people living with type 2 diabetes and health care team members is at the core of integrated care, and clinicians must recognize how language matters.

Language in diabetes care should be neutral, free of stigma, and based on facts; be strength-based focus on what is working , respectful, and inclusive; encourage collaboration; and be person-centered DSMES is a key intervention, as important to the treatment plan as the selection of pharmacotherapy 19 — DSMES is central to establishing and implementing the principles of care Fig.

DSMES programs usually involve face-to-face contact in group or individual sessions with trained educators, and key components of DSMES are shown in Supplementary Table 1 19 — Given the ever-changing nature of type 2 diabetes, DSMES should be offered on an ongoing basis.

Critical junctures when DSMES should be provided include at diagnosis, annually, when complications arise, and during transitions in life and care Supplementary Table 1 High-quality evidence has consistently shown that DSMES significantly improves knowledge, glycemic levels, and clinical and psychological outcomes, reduces hospital admissions and all-cause mortality, and is cost-effective 22 , 25 — DSMES is delivered through structured educational programs provided by trained diabetes care and education specialists termed DCES in the U.

DSMES can be provided using multiple approaches and in a variety of settings 20 , 31 , and it is important for the care team to know how to access local DSMES resources. DSMES supports the psychosocial care of people with diabetes but is not a replacement for referral for mental health services when they are warranted, for example, when diabetes distress remains after DSMES.

Psychiatric disorders, including disordered eating behaviors, are common, often unrecognized, and contribute to poor outcomes in diabetes The best outcomes from DSMES are achieved through programs with a theory-based and structured curriculum and with contact time of over 10 h While online programs may reinforce learning, a comprehensive approach to education using multiple methods may be more effective Emerging evidence demonstrates the benefits of telehealth or web-based DSMES programs 33 , and these were used with success during the coronavirus disease COVID pandemic 34 — Technologies such as mobile apps, simulation tools, digital coaching, and digital self-management interventions can be used to deliver DSMES and extend its reach to a broader segment of the population with diabetes and provide comparable or even better outcomes Greater HbA 1c reductions are demonstrated with increased engagement of people with diabetes 35 , However, data from trials of digital strategies to support behavior change are still preliminary in nature and quite heterogeneous 22 , Type 2 diabetes is a very heterogeneous disease with variable age at onset, related degree of obesity, insulin resistance, and tendency to develop complications 39 , Providing person-centered care that addresses multimorbidity and is respectful of and responsive to individual preferences and barriers, including the differential costs of therapies, is essential for effective diabetes management Shared decision-making, facilitated by decision aids that show the absolute benefit and risk of alternative treatment options, is a useful strategy to determine the best treatment course for an individual 42 — With compelling indications for therapies such as SGLT2i and GLP-1 RA for high-risk individuals with CVD, HF, or CKD, shared decision-making is essential to contextualize the evidence on benefits, safety, and risks.

Providers should evaluate the impact of any suggested intervention in the context of cognitive impairment, limited literacy, distinct cultural beliefs, and individual fears or health concerns. The health care system is an important factor in the implementation, evaluation, and development of the personalized approach.

Furthermore, social determinants of health—often out of direct control of the individual and potentially representing lifelong risk—contribute to medical and psychosocial outcomes and must be addressed to improve health outcomes.

Five social determinants of health areas have been identified: socioeconomic status education, income, and occupation , living and working conditions, multisector domains e. More granularity on social determinants of health as they pertain to diabetes is provided in a recent ADA review 47 , with a particular focus on the issues faced in the African American population provided in a subsequent report Environmental, social, behavioral, and emotional factors, known as psychosocial factors, also influence living with diabetes and achieving satisfactory medical outcomes and psychological well-being.

Thus, these multifaceted domains heterogeneity across individual characteristics, social determinants of health, and psychosocial factors challenge individuals with diabetes, their families, and their providers when attempting to integrate diabetes care into daily life Current principles of, and approaches to, person-centered care in diabetes Fig.

Such characteristics include comorbidities, clinical characteristics, and compelling indications for GLP-1 RA or SGLT2i for organ protection 6. Weight reduction has mostly been seen as a strategy to improve HbA 1c and reduce the risk for weight-related complications.

A higher magnitude of weight loss confers better outcomes. Weight loss may exert benefits that extend beyond glycemic management to improve risk factors for cardiometabolic disease and quality of life Glycemic management is primarily assessed with the HbA 1c test, which was the measure used in trials demonstrating the benefits of glucose lowering 2 , As with any laboratory test, HbA 1c measurement has limitations 2 , Discrepancies between measured HbA 1c levels and measured or reported glucose levels should prompt consideration that one of these may not be reliable 52 , Regular blood glucose monitoring BGM may help with self-management and medication adjustment, particularly in individuals taking insulin.

BGM plans should be individualized. People with type 2 diabetes and the health care team should use the monitoring data in an effective and timely manner. In people with type 2 diabetes not using insulin, routine glucose monitoring is of limited additional clinical benefit while adding burden and cost 54 , However, for some individuals, glucose monitoring can provide insight into the impact of lifestyle and medication management on blood glucose and symptoms, particularly when combined with education and support Technologies such as intermittently scanned or real-time continuous glucose monitoring CGM provide more information and may be useful for people with type 2 diabetes, particularly in those treated with insulin 53 , When using CGM, standardized, single-page glucose reports, such as the ambulatory glucose profile, can be uploaded from CGM devices.

They should be considered standard metrics for all CGM devices and provide visual cues for management opportunities.

Time in range is defined as the percentage of time that CGM readings are in the range 3. Time in range is associated with the risk of microvascular complications and can be used for assessment of glycemic management Additionally, time above and below range are useful variables for the evaluation of treatment regimens.

Particular attention to minimizing the time below range in those with hypoglycemia unawareness may convey benefit. Although this consensus report focuses on medication-taking behavior, the principles are pertinent to all aspects of diabetes care.

Multiple factors contribute to inconsistent medication use and treatment discontinuation among people with diabetes, including perceived lack of medication efficacy, fear of hypoglycemia, lack of access to medication, and adverse effects of medication Observed rates of medication adherence and persistence vary across medication classes and between agents; careful consideration of these differences may help improve outcomes Ultimately, individual preferences are major factors driving the choice of medications.

Even when clinical characteristics suggest the use of a particular medication based on the available evidence from clinical trials, preferences regarding route of administration, injection devices, side effects, or cost may prevent use by some individuals Therapeutic or clinical inertia describes a lack of treatment intensification when targets or goals are not met.

It also includes failure to de-intensify management when people are overtreated. Interventions targeting therapeutic inertia have facilitated improvements in glycemic management and timely insulin intensification 67 , For example, the involvement of multidisciplinary teams that include nonphysician providers with authorization to prescribe e.

This section summarizes the lifestyle and behavioral therapy, weight management interventions, and pharmacotherapy that support glycemic management in people with type 2 diabetes. Specific pharmacological treatment options are summarized in Table 1. CV, cardiovascular; CVOT, cardiovascular outcomes trial; DKA, diabetic ketoacidosis; DKD, diabetic kidney disease; DPP-4, dipeptidyl peptidase 4; eGFR, estimated glomerular filtration rate; GI, gastrointestinal; GIP, gastric inhibitory polypeptide; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; NASH, nonalcoholic steatohepatitis; MACE, major adverse cardiovascular events; SGLT2, sodium-glucose cotransporter 2; SQ, subcutaneous; T2DM, type 2 diabetes mellitus.

For agent-specific dosing recommendations, please refer to manufacturers' prescribing information. Nutrition therapy is integral to diabetes management, with goals of promoting and supporting healthy eating patterns, addressing individual nutrition needs, maintaining the pleasure of eating, and providing the person with diabetes with the tools for developing healthy eating Two core dimensions of MNT that can improve glycemic management include dietary quality and energy restriction.

There is no single ratio of carbohydrate, proteins, and fat intake that is optimal for every person with type 2 diabetes. Instead, individually selected eating patterns that emphasize foods with demonstrated health benefits, minimize foods shown to be harmful, and accommodate individual preferences with the goal of identifying healthy dietary habits that are feasible and sustainable are recommended.

A net energy deficit that can be maintained is important for weight loss 5 , 6 , 22 , 72 — Greater glycemic benefits were seen with the Mediterranean diet and low-carbohydrate diet Similar benefits have been ascribed to vegan and vegetarian diets There has been increased interest in time-restricted eating and intermittent fasting to improve metabolic variables, although with mixed, and modest, results.

In a meta-analysis there were no differences in the effect of intermittent fasting and continuous energy restriction on HbA 1c , with intermittent fasting having a modest effect on weight —1.

Fasting may increase the rates of hypoglycemia in those treated with insulin and sulfonylureas, highlighting the need for individualized education and proactive medication management during significant dietary changes Structured nutrition and lifestyle programs may be considered for glycemic benefit and can be adapted for specific cultural indications 83 — The Diabetes Remission Clinical Trial DiRECT demonstrated greater remission of diabetes with a weight management program than with usual best practice care in adults with type 2 diabetes within 6 years of diagnosis.

In the whole study population, remission directly varied with degree of weight loss At the 2-year follow-up, sustained remission correlated with extent of sustained weight loss. This should be balanced against potential negative effects on body composition, bone density, and frailty fractures 90 , Although there was no difference in the primary cardiovascular outcome or mortality rate between the intervention and the control groups, post hoc exploratory analyses suggested potential benefits in certain groups e.

Physical activity behaviors significantly impact cardiometabolic health in type 2 diabetes Fig. Regular aerobic exercise i. Resistance exercise i. This is important given the increased risk of impaired physical function at an earlier age in type 2 diabetes A wide range of physical activities, including leisure time activities, can significantly reduce HbA 1c levels 5 , 22 , , Beneficial effects are evident across the continuum of human movement, from breaking prolonged sitting with light activity to high-intensity interval training Healthy sleep is considered a key lifestyle component in the management of type 2 diabetes , with clinical practice guidelines promoting the importance of sleep hygiene Sleep disorders are common in type 2 diabetes and cause disturbances in the quantity, quality, and timing of sleep and are associated with an increased risk of obesity and impairments in daytime functioning and glucose metabolism , Additionally, obstructive sleep apnea affects over half of people with type 2 diabetes, and its severity is associated with blood glucose levels , The quantity of sleep is known to be associated in a U-shaped manner with health outcomes e.

By extending the sleep duration of short sleepers, it is possible to improve insulin sensitivity and reduce energy intake , Weight loss medications are effective adjuncts to lifestyle interventions and healthy behaviors for management of weight and have also been found to improve glucose control in people with diabetes Newer therapies have demonstrated very high efficacy for weight management in people with type 2 diabetes.

In the Semaglutide Treatment Effect in People with Obesity 2 STEP 2 trial, subcutaneous semaglutide 2. More than two-thirds of participants in the semaglutide 2. However, the weight loss was less pronounced than the Metabolic surgery should be considered as a treatment option in adults with type 2 diabetes who are appropriate surgical candidates , However, there is a strong association between duration of diabetes and the likelihood of postoperative diabetes remission.

People with more recently diagnosed diabetes are more likely to experience remission after metabolic surgery, and the likelihood of remission decreases significantly with duration of diabetes longer than about 5—8 years Even in people with diabetes who do not achieve postoperative diabetes remission, or relapse after initial remission, metabolic surgery is associated with better metabolic control than medical management , In the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently STAMPEDE trial, metabolic surgery was also associated with improvements in patient-reported outcomes related to physical health; however, measures of social and psychological quality of life did not improve It is important to note that many of these estimates of benefit included data from nonrandomized studies and compared outcomes with medical treatments for obesity that were less effective than those available today.

The SGLT2i are oral medications that reduce plasma glucose by enhancing urinary excretion of glucose. They have intermediate-to-high glycemic efficacy, with lower glycemic efficacy at lower estimated glomerular filtration rate eGFR.

However, their scope of use has significantly expanded based on cardiovascular and renal outcome studies 5 , This is discussed in the section Personalized Approach to Treatment Based on Individual Characteristics and Comorbidities: Recommended Process for Glucose-Lowering Medication Selection.

Evidence supporting their use is summarized in Table 1 , Recent data have increased confidence in the safety of the SGLT2i drug class , Their use is associated with increased risk for mycotic genital infections, which are reported to be typically mild and treatable.

While SGLT2i use can increase the risk of diabetic ketoacidosis DKA , the incidence is low, with a modest incremental absolute risk The SGLT2i cardiovascular outcome trials CVOTs have reported DKA rates of 0. Risk can be mitigated with education and guidance, including education on signs and symptoms of DKA that should prompt medical attention, and temporary discontinuation of the medication in clinical situations that predispose to ketoacidosis e.

The Dapagliflozin in Respiratory Failure in Patients With COVID DARE RCT demonstrated a low risk of DKA 0. placebo-treated participants with structured monitoring of acid—base balance and kidney function during inpatient use in adults admitted with COVID and at least one cardiometabolic risk factor without evidence of critical illness While early studies brought attention to several safety areas of interest acute kidney injury, dehydration, orthostatic hypotension, amputation, and fractures 5 , 6 , longer-term studies that have prospectively assessed and monitored these events , have not seen a significant imbalance in risks.

Analyses of SGLT2i outcome trial data also suggest that people with type 2 diabetes and peripheral arterial disease derive greater absolute outcome benefits from SGLT2i therapy than those without peripheral arterial disease, without an increase in risk of major adverse limb events In post hoc analyses, SGLT2i use has been associated with reduced incidence of serious and nonserious kidney-related adverse events in people with type 2 diabetes and CKD and greater full recovery from acute kidney injury GLP-1 RA augment glucose-dependent insulin secretion and glucagon suppression, decelerate gastric emptying, curb postmeal glycemic increments, and reduce appetite, energy intake, and body weight 5 , 6 , Beyond improving HbA 1c in adults with type 2 diabetes, specific GLP-1 RA have also been approved for reducing risk of MACE in adults with type 2 diabetes with established CVD dulaglutide, liraglutide, and subcutaneous semaglutide or multiple cardiovascular risk factors dulaglutide Table 1 and for chronic weight management subcutaneous liraglutide titrated to 3.

This is discussed in the sections Medications for Weight Loss in Type 2 Diabetes and Personalized Approach to Treatment Based on Individual Characteristics and Comorbidities: Recommended Process for Glucose-Lowering Medication Selection. GLP-1 RA are primarily available as injectable therapies subcutaneous administration , with one oral GLP-1 RA now available oral semaglutide The recent higher-dose GLP-1 RA studies have indicated incremental benefits for glucose and weight at higher doses of GLP-1 RA, with greater proportions of people achieving glycemic targets and the ability of stepwise dose escalation to improve gastrointestinal tolerability.

The Assessment of Weekly Administration of LY dulaglutide in Diabetes 11 AWARD trial evaluated higher doses of dulaglutide 3. Likewise, the SUSTAIN FORTE trial studied higher doses of once-weekly subcutaneous semaglutide 2.

The most common side effects of GLP-1 RA are gastrointestinal in nature nausea, vomiting, and diarrhea and tend to occur during initiation and dose escalation and diminish over time. Gradual up-titration is recommended to mitigate gastrointestinal effects , , Education should be provided when initiating GLP-1 RA therapy.

GLP-1 RA promote a sense of satiety, facilitating reduction in food intake. It is important to help people distinguish between nausea, a negative sensation, and satiety, a positive sensation that supports weight loss.

Mindful eating should be encouraged: eating slowly, stopping eating when full and not eating when not hungry. Smaller meals or snacks, decreasing intake of high-fat and spicy foods, moderating alcohol intake, and increasing water intake are also recommended.

Slower or flexible dose escalations can be considered in the setting of gastrointestinal intolerance , Data from CVOTs on other safety areas of interest pancreatitis, pancreatic cancer, and medullary thyroid cancer indicate that there is no increase in these risks with GLP-1 RA. GLP-1 RA are contraindicated in people at risk for the rare medullary thyroid cancer , that is, those with a history or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2, due to thyroid C-cell tumors seen in rodents treated with GLP-1 RA in preclinical studies.

Increased retinopathy complications seen in the SUSTAIN 6 CVOT appear attributable to the magnitude and rapidity of HbA 1c reductions in individuals with pre-existing diabetic retinopathy and high glycemic levels, as has been seen in previous studies with insulin , GLP-1 RA are also associated with higher risks of gallbladder and biliary diseases Because of its high efficacy in lowering HbA 1c , minimal hypoglycemia risk when used as monotherapy, weight neutrality with the potential for modest weight loss, good safety profile, and low cost, metformin has traditionally been recommended as first-line glucose-lowering therapy for the management of type 2 diabetes.

However, there is ongoing acceptance that other approaches may be appropriate. Notably, the benefits of GLP-1 RA and SGLT2i for cardiovascular and renal outcomes have been found to be independent of metformin use, and thus these agents should be considered in people with established or high risk of CVD, HF, or CKD, independent of metformin use — Early combination therapy based on the perceived need for additional glycemic efficacy or cardiorenal protection can be considered at treatment initiation to extend the time to treatment failure Metformin use may result in lower serum vitamin B 12 concentrations and worsening of symptoms of neuropathy; therefore, periodic monitoring and supplementation are generally recommended if levels are deficient, particularly in those with anemia or neuropathy , Dipeptidyl peptidase 4 inhibitors DPP-4i are oral medications that inhibit the enzymatic inactivation of endogenous incretin hormones, resulting in glucose-dependent insulin release and a decrease in glucagon secretion.

They have a more modest glucose-lowering efficacy and a neutral effect on weight and are well tolerated with minimal risk of hypoglycemia. CVOTs have demonstrated the cardiovascular safety without cardiovascular risk reduction of four DPP-4i saxagliptin, alogliptin, sitagliptin, and linagliptin Reductions in risk of albuminuria progression were noted with linagliptin in the Cardiovascular and Renal Microvascular Outcome Study With Linagliptin CARMELINA trial While generally well tolerated, an increased risk of HHF was found with saxagliptin, which is reflected in its label, and there have been rare reports of arthralgia and hypersensitivity reactions with the DPP-4i class The high tolerability and modest efficacy of DPP-4i may mean that they are suitable for specific populations and considerations.

For example, in a 6-month open-label RCT comparing a DPP-4i linagliptin with basal insulin glargine in long-term care and skilled nursing facilities, mean daily blood glucose was similar, with fewer hypoglycemic events with linagliptin compared with insulin Treatment of inpatient hyperglycemia with basal insulin plus DPP-4i has been demonstrated to be effective and safe in older adults with type 2 diabetes, with similar mean daily blood glucose but lower glycemic variability and fewer hypoglycemic episodes compared with the basal—bolus insulin regimen In May , the U.

Food and Drug Administration FDA approved tirzepatide, a GIP and GLP-1 RA, for once-weekly subcutaneous administration to improve glucose control in adults with type 2 diabetes as an addition to healthy eating and exercise.

In the Phase III clinical trial program, tirzepatide demonstrated superior glycemic efficacy to placebo , , subcutaneous semaglutide 1.

Additional metabolic benefits included improvements in liver fat content and reduced visceral and subcutaneous abdominal adipose tissue volume Based on meta-analysis findings, tirzepatide was superior to its comparators, including other long-acting GLP-1 RA, in reducing glucose and body weight, but was associated with increased odds for gastrointestinal adverse events, in particular nausea Similar warnings and precautions are included in the prescribing information for tirzepatide as for agents in the GLP-1 RA class.

Additionally, current short-term data from RCTs suggest that tirzepatide does not increase the risk of MACE versus comparators; however, robust data on its long-term cardiovascular profile will be available after completion of the SURPASS-CVOT trial Tirzepatide has received a positive opinion in the European Union EU.

As per the previous consensus report and update, sulfonylureas are assessed as having high glucose-lowering efficacy, but with a lack of durable effect, and the advantages of being inexpensive and accessible 5 , 6.

However, due to their glucose-independent stimulation of insulin secretion, they are associated with an increased risk for hypoglycemia. Sulfonylureas are also associated with weight gain, which is relatively modest in large cohort studies Use of sulfonylureas or insulin for early intensive blood glucose control in the UK Prospective Diabetes Study UKPDS significantly decreased the risk of microvascular complications, underscoring the importance of early and continued glycemic management Adverse cardiovascular outcomes with sulfonylureas in some observational studies have raised concerns, although findings from systematic reviews have found no increase in all-cause mortality rates compared with other active treatments The incidence of cardiovascular events was comparable in those treated with a sulfonylurea or pioglitazone in the Thiazolidinediones or Sulfonylureas and Cardiovascular Accidents Intervention Trial TOSCA.

IT , and no difference in the incidence of MACE was found in people at high cardiovascular risk treated with glimepiride or linagliptin , a medication whose cardiovascular safety was demonstrated in a population at high cardiovascular and renal risk Thiazolidinediones TZDs are oral medications that increase insulin sensitivity and are of high glucose-lowering efficacy 5 , 6.

TZDs have a high durability of glycemic response, most likely through a potent effect on preserving β-cell function In the Prospective Pioglitazone Clinical Trial in Macrovascular Events PROactive in adults with type 2 diabetes and macrovascular disease, a reduction in secondary cardiovascular end points was seen, although significance was not achieved for the primary outcome Beneficial effects on nonalcoholic fatty liver disease NAFLD and nonalcoholic steatohepatitis NASH have been seen with pioglitazone , However, these benefits must be balanced against possible side effects of fluid retention and congestive HF , , , weight gain — , , , and bone fracture , Side effects can be mitigated by using lower doses and combining TZD therapy with other medications SGLT2i and GLP-1 RA that promote weight loss and sodium excretion , The previous consensus report and update provide detailed descriptions of the different insulins 5 , 6.

The primary advantage of insulin therapy is that it lowers glucose in a dose-dependent manner and thus can address almost any level of blood glucose. However, its efficacy and safety are largely dependent on the education and support provided to facilitate self-management 5 , 6.

Numerous formulations of insulin are available, with advances in therapy geared toward better mimicking physiological insulin release patterns. Challenges of insulin therapy include weight gain, the need for education and titration for optimal efficacy, risk of hypoglycemia, the need for regular glucose monitoring, and cost.

The approval of biosimilar insulins may improve accessibility at lower treatment costs. Both insulin glargine U and insulin degludec have demonstrated cardiovascular safety in dedicated CVOTs , Comprehensive education on self-monitoring of blood glucose, diet, injection technique, self-titration of insulin, and prevention and adequate treatment of hypoglycemia are of utmost importance when initiating and intensifying insulin therapy 5 , 6.

Novel formulations and devices, including prefilled syringes, auto-injectors, and intranasal insufflators, are now available to administer glucagon in the setting of severe hypoglycemia and should be considered for those at risk Starting doses of basal insulin NPH or analog are estimated based on body weight 0.

A modest but significant reduction in HbA 1c and the risk of total and nocturnal hypoglycemia has been observed for basal insulin analogs versus NPH insulin Longer-acting basal insulin analogs have a lower risk of hypoglycemia than earlier generations of basal insulin, although they may cost more.

Concentrated insulins allow injection of a reduced volume 5. Cost and access are important considerations and can contribute to treatment discontinuation. Short- and rapid-acting insulin can be added to basal insulin to intensify therapy to address prandial blood glucose levels. Premixed insulins combine basal insulin with mealtime insulin short- or rapid-acting in the same vial or pen, retaining the pharmacokinetic properties of the individual components.

Premixed insulin may offer convenience for some but reduces treatment flexibility. Rapid-acting insulin analogs are also formulated as premixes, combining mixtures of the insulin with protamine suspension and the rapid-acting insulin.

Analog-based mixtures may be timed in closer proximity to meals. Education on the impact of dietary nutrients on glucose levels to reduce the risk of hypoglycemia while using mixed insulin is important.

Insulins with different routes of administration inhaled, bolus-only insulin delivery patch pump are also available — Two fixed-ratio combinations of GLP-1 RA with basal insulin analogs are available: insulin degludec plus liraglutide IDegLira and insulin glargine plus lixisenatide iGlarLixi.

The combination of basal insulin with GLP-1 RA results in greater glycemic lowering efficacy than the monocomponents, with less weight gain and lower rates of hypoglycemia than with intensified insulin regimens, and better gastrointestinal tolerability than with GLP-1 RA alone , In studies of people with type 2 diabetes inadequately controlled on basal insulin or GLP-1 RA, switching to a fixed-ratio combination of basal insulin and GLP-1 RA demonstrated significant improvements in blood glucose levels and achievement of glycemic goals with fewer hypoglycemic events than with basal insulin alone — α-Glucosidase inhibitors improve glycemic control by reducing postprandial glycemic excursions and glycemic variability and may provide specific benefits in cultures and settings with high carbohydrate consumption or reactive hypoglycemia , Other glucose-lowering medications i.

There was no new evidence that impacts clinical practice. In a network meta-analysis of trials assessing glucose-lowering medications from nine drug classes, the greatest reductions in HbA 1c were seen with insulin regimens and GLP-1 RA A network meta-analysis comparing the effects of glucose-lowering therapy on body weight and blood pressure indicates that the greatest efficacy for reducing body weight is seen with subcutaneous semaglutide followed by the other GLP-1 RA and SGLT2i, and the greatest reduction in blood pressure is seen with the SGLT2i and GLP-1 RA classes As discussed above, the novel GIP and GLP-1 RA tirzepatide was associated with greater glycemic and weight loss efficacy than semaglutide 1 mg weekly The underlying pathophysiology of type 2 diabetes is complex, with multiple contributing abnormalities resulting in a naturally progressive disease and increasing HbA 1c over time in many.

While traditional recommendations have focused on the stepwise addition of therapy, allowing for clear delineation of positive and negative effects of new drugs, there are data to suggest benefits of combination approaches in diabetes care.

Combination therapy has several potential advantages, including 1 increased durability of the glycemic effect — , addressing therapeutic inertia, 2 simultaneous targeting of the multiple pathophysiological processes characterized by type 2 diabetes, and 3 impacts on medication burden, medication-taking behavior, and treatment persistence, and 4 complementary clinical benefits e.

Insulin glargine and liraglutide were significantly, albeit modestly, more effective at achieving and maintaining HbA 1c targets. Liraglutide exhibited a lower risk than the pooled effect of the other three medications on a composite cardiovascular outcome comprising MACE, revascularization, or HF or unstable angina requiring hospitalization , In people with established CVD or with a high risk for CVD, GLP-1 RA were prioritized over SGLT2i.

Given their favorable drug class effect in reducing HHF and progression of CKD, SGLT2i were prioritized in people with HF, particularly those with a reduced ejection fraction, or CKD. Since , additional cardiovascular, kidney, and HF outcome trials have been completed, particularly with SGLT2i.

In addition, updated meta-analyses have been published that compare subgroup populations based on clinically relevant characteristics, such as presence of CVD, use of background therapy with metformin, stage of CKD, history of HF, and age. Collectively, this new evidence was systematically retrieved and appraised to be incorporated into these clinical practice recommendations Fig.

Hyperglycemia can also occur as a result of:. Waking up during the night and testing blood sugar can effectively determine whether these peaks result from the dawn phenomenon or other causes.

Hyperglycemia is high blood glucose levels, while hypoglycemia is low blood glucose levels. This recommendation can vary from person to person.

Very low blood glucose levels can be harmful and require immediate treatment. Some symptoms of excessively low blood glucose include:. If blood glucose levels become severely low, the brain can stop functioning properly.

This can cause symptoms such as:. A person can only know if they have hypoglycemia by testing their blood sugar levels. If that is not possible, the American Diabetes Association suggests that a person take steps to treat hypoglycemia as recommended by their doctor or seek medical attention if symptoms are severe.

Many people experience an increase in blood sugar levels after eating an unusually large meal that is high in carbohydrates. People who experience consistent hyperglycemia may have problems with low or inefficiently used insulin caused by diabetes.

Insulin is a hormone produced in the pancreas that allows cells to use glucose for generating energy and functioning normally. When insulin is low or inefficient, diabetes may develop.

There are two types of diabetes: Type I diabetes occurs when the body does not produce insulin. Type 2 diabetes occurs when the body does not use insulin effectively. As a result, glucose remains in the blood and circulates in the body. Over time the body may also stop producing adequate levels of insulin in people with type 2 diabetes.

However, this does not happen in all cases of type 2 diabetes. People who are overweight or have obesity and do not get enough physical activity may have continuously high amounts of sugar in the blood. This makes the body resistant to insulin, meaning glucose cannot enter the cells and builds up in the blood.

Eventually, this can lead to type 2 diabetes. When blood sugar levels are consistently high because of diabetes, a range of health problems might develop, including the following:. Other diabetic skin conditions can cause spots and lesions to develop, which may cause pain and itching.

These include :. Read more about diabetic skin conditions. Consistently high blood sugar can damage the nerves in several ways:. Read more about the types of neuropathy. People with diabetes with consistently high blood sugar levels might experience diabetic retinopathy.

This causes damage to blood vessels in the back of the eye, leading to vision loss and possible blindness. Having diabetes significantly increases the risk of both glaucoma and cataracts. DKA is a life threatening condition that occurs if a person does not treat severe hyperglycemia.

It is most common in people with type 1 diabetes. If a person with diabetes does not take steps to control their blood sugar levels, cells become less sensitive to insulin. When there is insufficient insulin in the body or the cells do not respond, and glucose cannot access the cells, the body uses fats for energy instead.

The body produces ketones by breaking down fats. The body cannot handle a high level of ketones. While it can get rid of some in the urine, ketones may eventually build up, causing the blood to become too acidic.

If you take insulin by syringe or pen, and your blood sugar has not responded within 2 hours, you can take a second dose using the same correction dose. Remember that insulin takes 20 to 30 minutes to work and will continue to work for 4 to 5 hours.

If you get hyperglycemia often, talk with your doctor. They might adjust your medication or suggest you talk with a dietitian about meals and exercise.

Also, a CGM can help you keep track of changes in your blood sugar throughout the day. Your body releases stress hormones when you are sick, which can cause hyperglycemia.

Keep taking your insulin and other diabetes medications, even if you are throwing up. They might also want you to call if:. Managing blood sugar during and after physical activity is important and is something that a lot of people with T1D have questions about. JDRF has a number of resources available for people with T1D and their families, many of which can be found here.

If you are using an insulin pump, talk to your diabetes team about how to best manage hyperglycemia. In general, be sure to check your pump first. Make sure all parts are connected and working correctly. Check your bolus history and temporary basal rate.

Also check your insulin to make sure it has not expired or gotten too warm. If you use a CGM, try not to react to it too often. Controlling blood sugar is very important in children with T1D.

Long-term hyperglycemia damages the eyes, heart, kidneys, and nerves, so it is important to maintain good glucose control to minimize the chances of this damage.

Importantly, they should test their blood sugar before driving a car. Click here for a downloadable guide on causes, symptoms and treatments of hyperglycemia. We value your privacy.

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T1D Resources Overview Newly Diagnosed T1D Basics Life with T1D Daily Management For Healthcare Professionals Recursos en Español. High Blood Sugar Hyperglycemia : Symptoms, Causes, and Treatment What is Hyperglycemia?

How Does Hyperglycemia Happen? Other things that can cause hyperglycemia include: Caffeine Stress Illness Medications Hormone changes Intensive exercise Also, every day around 4 to 5 am, your body releases hormones as it is getting ready to wake up.

How Do I Know if I Have Hyperglycemia? What Are The Risks of Hyperglycemia? How to Test for Ketones You can use a urine test strip or blood ketone meter and ketone test strip to test for ketones at home.

The following ranges are generally used: 0. Treating Hyperglycemia The first thing you should do to treat hyperglycemia is take insulin. Wait 1 hour and test your blood sugar again. If it is lower, check your blood sugar before your next meal. Take your next insulin dose at the usual time.

If your blood sugar did not go down, take a dose of insulin by syringe or pen and check your blood sugar in 1 hour. Consider changing the infusion site because the insulin might not be absorbing properly and the infusion set or catheter may not be working properly.

It requires prompt medical attention. Chronic hyperglycemia occurs when a person has elevated blood sugar levels over a long period. In general, this means they are having difficulty managing their condition.

Both acute and chronic hyperglycemia can cause potentially life threatening complications. When a person has diabetes, there are several different potential underlying causes of acute hyperglycemia. They include :. Early signs of hyperglycemia can include :.

If left untreated, a person may develop diabetic ketoacidosis DKA. This is potentially life threatening and occurs when the body starts to break down fats for energy.

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.

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Medical News Today. Health Conditions Health Products Discover Tools Connect. What does the term acute hyperglycemia mean? Medically reviewed by Kelly Wood, MD — By Jenna Fletcher on April 21, Definition Acute vs.

chronic Causes Symptoms Treatment Summary Acute hyperglycemia is a sudden, severe onset of high blood sugar levels that requires medical attention.