g The dosage of insulin must be determined individually
for each patient and should be adjusted as necessary
according to the results of regular monitoring of bloodglucose concentrations. h
Persistent poor glucose control, leading to erratic insulin
requirements or episodes of hypoglycaemia, may be due to
many factors, including adherence, injection technique,
injection site problems, blood-glucose monitoring skills,
lifestyle issues (including diet, exercise and alcohol intake),
psychological issues, and organic causes such as renal
disease, thyroid disorders, coeliac disease, Addison’s disease
Infection, stress, accidental or surgical trauma can all
increase the required insulin dose. Insulin requirements may
be decreased (and therefore susceptibility to hypoglycaemia
increased) by physical activity, intercurrent illness, reduced
food intake, impaired renal function, and in certain
Risks of hypoglycaemia with insulin
g Hypoglycaemia is an inevitable adverse effect of insulin
treatment, and patients should be advised of the warning
signs and actions to take (for guidance on management, see
Impaired awareness of hypoglycaemia can occur when the
ability to recognise usual symptoms is lost, or when the
symptoms are blunted or no longer present. Patients’
awareness of hypoglycaemia should be assessed annually
using the Gold score or the Clarke score. h
An increase in the frequency of hypoglycaemic episodes
may reduce the warning symptoms experienced by the
patient. Impaired awareness of symptoms below 3 mmol/litre
is associated with a significantly increased risk of severe
hypoglycaemia. Beta-blockers can also blunt hypoglycaemic
awareness, by reducing warning signs such as tremor.
Loss of warning of hypoglycaemia among insulin-treated
patients can be a serious hazard, especially for drivers and
those in dangerous occupations. Advice should be given in
line with the Driver and Vehicle Licensing Agency (DVLA)
guidance (see Driving under Diabetes p. 682).
g To restore the warning signs, episodes of
hypoglycaemia must be minimised. Insulin regimens, doses
and blood-glucose targets should be reviewed and
considered. Patients should receive structured education to
ensure they are following the principles of a flexible insulin
regimen correctly, with additional education regarding
avoiding and treating hypoglycaemia for those who continue
to have impaired awareness. Relaxation of individualised
blood-glucose targets should be avoided as a strategy to
improve impaired awareness of symptoms. If recurrent
severe episodes of hypoglycaemia continue despite
appropriate interventions, the patient should be referred to a
There is conflicting evidence regarding reports that some
patients may experience loss of awareness of hypoglycaemia
after transfer from animal to human insulin; clinical studies
do not confirm that human insulin decreases hypoglycaemia
Manufacturers advise any switch between brands or
formulation of insulin (including switching from animal to
human insulin) should be done under strict supervision; a
change in dose may be required.
g Patients should be advised on the safe disposal of
lancets, single-use syringes, and needles, and should be
provided with suitable disposal containers. Arrangements
should be made for the suitable disposal of these containers.
Lancets, needles, syringes, and accessories are listed under
Hypodermic Equipment in Part IXA of the Drug Tariff (Part
III of the Northern Ireland Drug Tariff, Part 3 of the Scottish
Drug Tariff). The drug Tariffs can be access online at:
. National Health Service Drug Tariff for England and Wales:
www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliancecontractors/drug-tariff
. Health and Personal Social Services for Northern Ireland
www.hscbusiness.hscni.net/services/2034.htm
www.isdscotland.org/Health-Topics/Prescribing-and-Medicines/
Patients with type 1 diabetes may be eligible for the
Medicines Use Review service provided by a community
pharmacist. For further information, see Advanced Pharmacy
Services in Guidance on prescribing p. 1.
Type 1 diabetes in adults: diagnosis and management.
National Institute for Health and Care Excellence. Clinical
For recommended insulin regimens see Type 1 diabetes
p. 684 and Type 2 diabetes p. 686.
Insulin is a polypeptide hormone secreted by pancreatic
beta-cells. Insulin increases glucose uptake by adipose tissue
and muscles, and suppresses hepatic glucose release. The
role of insulin is to lower blood-glucose concentrations in
order to prevent hyperglycaemia and its associated
microvascular, macrovascular and metabolic complications.
The natural profile of insulin secretion in the body consists
of basal insulin (a low and steady secretion of background
insulin that controls the glucose continuously released from
the liver) and meal-time bolus insulin (secreted in response
to glucose absorbed from food and drink).
Three types of insulin are available in the UK: human
insulin, human insulin analogues, and animal insulin.
Animal insulins are extracted and purified from animal
sources (bovine or porcine insulin). Although widely used in
the past, animal insulins are no longer initiated in people
with diabetes but may still be used by some adult patients
who cannot, or do not wish to, change to human insulins.
Human insulins are produced by recombinant DNA
technology and have the same amino acid sequence as
endogenous human insulin. Human insulin analogues are
produced in the same way as human insulins, but the insulin
is modified to produce a desired kinetic characteristic, such
as an extended duration of action or faster absorption and
Immunological resistance to insulin is uncommon and
true insulin allergy is rare. Human insulin and insulin
analogues are less immunogenic than animal insulins.
Insulin is inactivated by gastro-intestinal enzymes and must
therefore be given by injection; the subcutaneous route is
ideal in most circumstances. Insulin should be injected into a
body area with plenty of subcutaneous fat—usually the
abdomen (fastest absorption rate) or outer thighs/buttocks
(slower absorption compared with the abdomen or inner
Absorption from a limb site can vary considerably (by as
much as 20–40%) day-to-day, particularly in children. Local
tissue reactions, changes in insulin sensitivity, injection site,
blood flow, depth of injection, and the amount of insulin
injected can all affect the rate of absorption. Increased blood
flow around the injection site due to exercise can also
g Lipohypertrophy can occur due to repeatedly
injecting into the same small area, and can cause erratic
absorption of insulin, and contribute to poor glycaemic
control. Patients should be advised not to use affected areas
for further injection until the skin has recovered.
Lipohypertrophy can be minimised by using different
injection sites in rotation. Injection sites should be checked
for signs of infection, swelling, bruising, and
lipohypertrophy before administration. h
Insulin preparations can be broadly categorised into three
groups based on their time-action profiles: short-acting
insulins (including soluble insulin and rapid-acting insulins),
intermediate-acting insulins and long-acting insulins. The
duration of action of each particular type of insulin varies
considerably from one patient to another, and needs to be
Short-acting insulins have a short duration and a relatively
rapid onset of action, to replicate the insulin normally
produced by the body in response to glucose absorbed from a
meal. These are available as soluble Insulin p. 685 (human
glulisine p. 714 and insulin lispro p. 714).
Soluble insulin is usually given subcutaneously but some
preparations can be given intravenously and
intramuscularly. For maintenance regimens, it is usual to
inject the insulin 15 to 30 minutes before meals, depending
on the insulin preparation used.
When injected subcutaneously, soluble insulin has a rapid
onset of action (30 to 60 minutes), a peak action between 1
and 4 hours, and a duration of action of up to 9 hours.
When injected intravenously, soluble insulin has a short
half-life of only a few minutes and its onset of action is
Soluble insulin administered intravenously is the most
appropriate form of insulin for use in diabetic emergencies
e.g. Diabetic ketoacidosis p. 689 and peri-operatively.
Insulin aspart, insulin glulisine, and insulin lispro have a
faster onset of action (within 15 minutes) and shorter
duration of action (approximately 2–5 hours) than soluble
insulin, and are usually given by subcutaneous injection.
g For maintenance regimens, these insulins should
ideally be injected immediately before meals. Rapid-acting
insulin, administered before meals, has an advantage over
short-acting soluble insulin in terms of improved glucose
control, reduction of HbA1c, and reduction in the incidence
of severe hypoglycaemia, including nocturnal
The routine use of post-meal injections of rapid-acting
insulin should be avoided—when given during or after meals,
they are associated with poorer glucose control, an increased
risk of high postprandial-glucose concentration, and
Intermediate-acting insulins (isophane insulin p. 716) have
an intermediate duration of action, designed to mimic the
effect of endogenous basal insulin. When given by
subcutaneous injection, they have an onset of action of
approximately 1–2 hours, a maximal effect at 3–12 hours,
and a duration of action of 11–24 hours.
Isophane insulin is a suspension of insulin with
protamine; it may be given as one or more daily injections
alongside separate meal-time short-acting insulin
insulin regimens see Type 1 diabetes p. 684 and Type 2
can be supplied (biphasic isophane insulin p. 715, biphasic
insulin aspart p. 716 and biphasic insulin lispro p. 716).
Biphasic insulins (biphasic isophane insulin, biphasic
insulin aspart, biphasic insulin lispro) are pre-mixed insulin
insulin) and an intermediate-acting insulin.
The percentage of short-acting insulin varies from
15% to 50%. These preparations should be administered by
subcutaneous injection immediately before a meal.
Like intermediate-acting insulins, the long-acting insulins
(protamine zinc insulin p. 719, insulin zinc suspension
p. 718, insulin detemir p. 717, insulin glargine p. 718, insulin
degludec p. 717) mimic endogenous basal insulin secretion,
but their duration of action may last up to 36 hours. They
achieve a steady-state level after 2–4 days to produce a
Insulin glargine and insulin degludec are given once daily
and insulin detemir is given once or twice daily according to
individual requirements. The older long-acting insulins,
(insulin zinc suspension and protamine zinc insulin) are now
Type 2 diabetes is a chronic metabolic condition
characterised by insulin resistance. Insufficient pancreatic
insulin production also occurs progressively over time,
It is commonly associated with obesity, physical inactivity,
raised blood pressure, dyslipidaemia and a tendency to
develop thrombosis; therefore it increases cardiovascular
risk. It is associated with long-term microvascular and
macrovascular complications, together with reduced quality
Type 2 diabetes typically develops later in life but is
increasingly diagnosed in children, despite previously being
considered a disease of adulthood.
Treatment is aimed at minimising the risk of long-term
microvascular and macrovascular complications by effective
blood-glucose control and maintenance of HbA1c at or
below the target value set for each individual patient.
g Weight loss, smoking cessation and regular exercise
can help to reduce hyperglycaemia and reduce
cardiovascular risk, and should be encouraged (with input
from a dietitian where appropriate). For guidance on
reducing cardiovascular risk, see Cardiovascular disease risk
assessment and prevention p. 189. Antidiabetic drugs should
be prescribed to augment lifestyle interventions, when these
changes are not adequate to control blood-glucose alone.
686 Diabetes mellitus and hypoglycaemia BNF 78
There are several classes of non-insulin antidiabetic drugs
available for the treatment of type 2 diabetes.g The
choice of drug should be based on effectiveness, safety,
tolerability and should also take into consideration the
patient’s comorbidities and concomitant medication. For
recommended treatment regimens and the place in therapy
of each drug, see Drug treatment, antidiabetic drugs (below).
blood-glucose concentrations. It does not stimulate insulin
secretion and therefore, when given alone, does not cause
hypoglycaemia.g The dose of standard-release
metformin hydrochloride should be increased gradually to
standard treatment is not tolerated. h
The sulfonylureas (glibenclamide p. 709, gliclazide p. 709,
glimepiride p. 709, glipizide p. 710, tolbutamide p. 710) may
cause hypoglycaemia; it is more likely with long-acting
sulfonylureas such as glibenclamide, which have been
associated with severe, prolonged and sometimes fatal cases
of hypoglycaemia. Sulfonylureas are also associated with
modest weight gain, probably due to increased plasmainsulin concentrations.
Acarbose p. 692 has a poorer anti-hyperglycaemic effect
than many other antidiabetic drugs, including the
sulfonylureas, metformin hydrochloride, and pioglitazone
The meglitinides, nateglinide p. 701 and repaglinide
p. 702, have a rapid onset of action and short duration of
activity. These drugs can be used flexibly around mealtimes
and adjusted to fit around individual eating habits which
may be beneficial for some patients, but generally are a less
preferred option than the sulfonylureas.
The thiazolidinedione, pioglitazone, is associated with
several long-term risks and its ongoing benefit to the patient
should be reviewed regularly and treatment stopped if
response is insufficient (see Important safety information
The dipeptidylpeptidase-4 inhibitors (gliptins), alogliptin
p. 694, linagliptin p. 694, sitagliptin p. 696, saxagliptin
p. 695, and vildagliptin p. 697, do not appear to be associated
with weight gain and have less incidence of hypoglycaemia
The sodium glucose co-transporter 2 inhibitors,
canagliflozin p. 702, dapagliflozin p. 704, and empagliflozin
p. 706, may be suitable for some patients when first-line
options are not appropriate.g Canagliflozin and
empagliflozin can be beneficial in patients with type 2
diabetes and established cardiovascular disease. h Sodium
glucose co-transporter 2 inhibitors are associated with a risk
The glucagon-like peptide-1 receptor agonists, dulaglutide
p. 698, exenatide p. 698, liraglutide p. 699 and lixisenatide
p. 700, should be reserved for combination therapy when
other treatment options have failed.g Liraglutide has
proven cardiovascular benefit and should be considered in
patients with type 2 diabetes and established cardiovascular
g Metformin hydrochloride (initiated by a specialist) is
prescribed as an insulin sensitising drug in women with
polycystic ovary syndrome who are not planning pregnancy
[unlicensed indication] h. Long-term benefit or superiority
over other treatment options has not been confirmed by
good quality evidence. Metformin hydrochloride may
improve short-term insulin sensitivity and reduce androgen
concentrations, but there is insufficient supporting evidence
that metformin improves weight gain, hirsutism, acne or
regulation of the menstrual cycle. Treatment should only be
initiated by a specialist. Metformin hydrochloride does not
exert a hypoglycaemic action in non-diabetic patients except
Drug treatment, antidiabetic drugs
g Type 2 diabetes should initially be treated with a single
oral antidiabetic drug. A target HbA1c concentration of
48 mmol/mol (6.5%) is generally recommended when type 2
diabetes is managed by diet and lifestyle alone or when
combined with a single antidiabetic drug not associated with
hypoglycaemia (such as metformin hydrochloride). Adults
prescribed a single drug associated with hypoglycaemia
(such as a sulphonylurea), or two or more antidiabetic drugs
in combination, should usually aim for an HbA1c
concentration of 53 mmol/mol (7.0%). Targets may differ and
should be individualised and agreed with each patient.
are older, frail, or where tight blood-glucose control is not
appropriate or poses a high risk of the consequences of
If HbA1c concentrations are poorly controlled despite
treatment with a single drug (usually considered to be a rise
of HbA1c to 58 mmol/mol (7.5%) or higher), the drug
treatment should be intensified, alongside reinforcement of
advice regarding diet, lifestyle, and adherence to drug
When two or more antidiabetic drugs are prescribed, an
HbA1c concentration target of 53 mmol/mol (7.0%) is
recommended for patients in which it is appropriate, but a
relaxation of the target may be more appropriate in some
individual cases (for example, those at high risk of the
consequences of hypoglycaemia, poor life expectancy, or
g Metformin hydrochloride is recommended as the first
choice for initial treatment for all patients, due to its positive
effect on weight loss, reduced risk of hypoglycaemic events
and the additional long-term cardiovascular benefits
If metformin is contra-indicated or not tolerated, see
Alternative non-metformin regimens below.
First intensification of treatment
g If metformin hydrochloride (alongside modification to
diet) does not control HbA1c to below the agreed threshold,
treatment should be intensified, and metformin
hydrochloride combined with one of the following:
. a sulfonylurea (glibenclamide, gliclazide, glimepiride,
. a dipeptidylpeptidase-4 inhibitor (linagliptin, saxagliptin,
sitagliptin, or vildagliptin);
. a sodium glucose co-transporter 2 inhibitor (canagliflozin,
dapagliflozin or empagliflozin) only when sulfonylureas
are contra-indicated or not tolerated, or if the patient is at
significant risk of hypoglycaemia or its consequences. h
g Elderly patients or those with renal impairment are at
particular risk of hypoglycaemia; if a sulfonylurea is
indicated, a shorter-acting sulfonylurea, such as gliclazide
p. 709 or tolbutamide p. 710 should be prescribed. l
The place in therapy of alogliptin p. 694 (a
dipeptidylpeptidase-4 inhibitor) is not yet known.
Second intensification of treatment
g If dual therapy is unsuccessful, treatment should be
intensified again, and one of the following triple therapy
. Metformin hydrochloride p. 692 and a
dipeptidylpeptidase-4 inhibitor and a sulfonylurea;
. Metformin hydrochloride and pioglitazone p. 710 and a
. Metformin hydrochloride and a sulfonylurea and one of
the sodium glucose co-transporter 2 inhibitors;
. Metformin hydrochloride and pioglitazone and a sodium
glucose co-transporter 2 inhibitor (canagliflozin p. 702 or
empagliflozin p. 706; note that dapagliflozin is not
recommended in a triple therapy regimen with
Glucagon-like peptide-1 receptor agonists
g If triple therapy with metformin hydrochloride and two
other oral drugs is tried and is not effective, not tolerated or
contra-indicated, a glucagon-like peptide-1 receptor
agonist may be prescribed as part of a triple combination
regimen with metformin hydrochloride and a sulfonylurea.
These should only be prescribed for patients who have a
or above (adjusted for ethnicity) and who
also have specific psychological or medical problems
associated with obesity; or for those who have a BMI lower
than 35 kg/m2 but for whom insulin therapy would have
significant occupational implications or if the weight loss
associated with glucagon-like peptide-1 receptor agonists
would benefit other significant obesity-related
After 6 months, the drug should be reviewed and only
continued if there has been a beneficial metabolic response
(a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a
weight loss of at least 3% of initial body-weight).
Insulin should only be prescribed in combination with a
glucagon-like peptide-1 receptor agonist under specialist
care advice and with ongoing support from a consultant-led
Alternative non-metformin regimens
g If metformin is contra-indicated or not tolerated, initial
treatment should be single therapy with:
. a sulfonylurea (glibenclamide p. 709, gliclazide,
glimepiride p. 709, glipizide p. 710, or tolbutamide) (first
. a dipeptidyl peptidase-4 inhibitor (linagliptin p. 694,
saxagliptin p. 695, sitagliptin p. 696, or vildagliptin p. 697),
The sodium glucose co-transporter 2 inhibitors
canagliflozin, dapagliflozin p. 704, or empagliflozin are also
inhibitor would otherwise be prescribed and neither a
sulfonylurea nor pioglitazone is appropriate.
g Repaglinide p. 702 is also an effective alternative
option for single therapy, but it has a limited role in
treatment because, should an intensification of treatment be
required, it is not licensed to be used in any combination
other than with metformin hydrochloride; it would therefore
require a complete change of treatment in those patients
who have started it due to intolerance or contra-indication
g If the initial single drug does not control HbA1c to
below the agreed threshold, treatment should be intensified
and one of the following dual combinations prescribed:
. a dipeptidylpeptidase-4 inhibitor and pioglitazone;
. a dipeptidylpeptidase-4 inhibitor and a sulfonylurea; or
. Pioglitazone and a sulfonylurea .
If dual therapy does not provide adequate glucose control,
insulin-based treatment should be considered—see Drug
g When indicated for intensification, insulin (see also,
Insulin p. 685) should be started with a structured support
programme covering insulin dose titration, injection
technique, self-monitoring, and knowledge of dietary effects
and glucose control. Metformin hydrochloride should be
continued unless it is contra-indicated or not tolerated.
Other antidiabetic drugs should be reviewed and stopped if
Recommended insulin regimens include:
. human isophane insulin p. 716 injected once or twice
daily, according to requirements;
particularly appropriate if HbA1c is 75 mmol/mol (9.0%) or
. Insulin detemir p. 717 or insulin glargine p. 718 as an
alternative to human isophane insulin. This can be
preferable if a once daily injection would be beneficial (for
example if assistance is required to inject insulin), or if
recurrent symptomatic hypoglycaemic episodes are
with oral glucose-lowering drugs. Also consider switching
to insulin detemir or insulin glargine from human
isophane insulin if significant hypoglycaemia is
problematic, or in patients who cannot use the device
needed to inject human isophane insulin;
human soluble insulin) can be preferable for patients who
prefer injecting insulin immediately before a meal, or if
hypoglycaemia is a problem, or if blood-glucose
concentrations rise markedly after meals.
When starting insulin therapy, bedtime basal insulin
should be initiated and the dose titrated against morning
(fasting) glucose. Patients who are prescribed a basal insulin
regimen (human isophane insulin, insulin detemir or insulin
glargine) should be monitored for the need for short-acting
insulin before meals (or a biphasic insulin preparation).
Patients who are prescribed a biphasic insulin should be
monitored for the need for a further injection of short-acting
insulin before meals or for a change to a basal-bolus regimen
with human isophane insulin or insulin detemir or insulin
glargine if blood-glucose control remains inadequate. h
Patients with type 2 diabetes may be eligible for the New
Medicines Service / Medicines Use Review service provided
by a community pharmacist. For further information, see
Advanced Pharmacy Services in Guidance on prescribing p. 1.
Type 2 diabetes in adults: management. National Institute
for Health and Care Excellence. Clinical guideline NG28.
Pharmacological management of glycaemic control in
people with type 2 diabetes. Scottish Intercollegiate
Guidelines Network. Clinical guideline 154. November 2017.
www.sign.ac.uk/assets/sign154.pdf
Diabetic complications 10-May-2018
Diabetes and cardiovascular disease
Diabetes is a strong risk factor for cardiovascular disease.
g Other risk factors for cardiovascular disease that should
688 Diabetes mellitus and hypoglycaemia BNF 78
also be addressed are: smoking, hypertension, obesity, and
dyslipidaemia. hCardiovascular risk in patients with
diabetes can be further reduced by the use of an ACE
inhibitor (or an angiotensin-II receptor antagonist) and
lipid-regulating drugs. For full guidance on the assessment
and prevention of cardiovascular disease, see Cardiovascular
disease risk assessment and prevention p. 189.
g In diabetic patients with nephropathy, blood pressure
should be reduced to the lowest achievable level to slow the
rate of decline of glomerular filtration rate and reduce
proteinuria. Provided there are no contra-indications, all
diabetic patients with nephropathy causing proteinuria or
with established microalbuminuria should be treated with an
ACE inhibitor or an angiotensin-II receptor antagonist, even
if the blood pressure is normal. ACE inhibitors or
angiotensin-II receptor antagonists should also be given as
monotherapy, or combined therapy, in patients with chronic
kidney disease and proteinuria, to reduce the rate of
progression of chronic kidney disease. h
ACE inhibitors can potentiate the hypoglycaemic effect of
insulin and oral antidiabetic drugs; this effect is more likely
during the first weeks of combined treatment and in patients
See also treatment of hypertension in diabetes in
g Optimal diabetic control is beneficial for the
management of painful neuropathy. Monotherapy with
antidepressant drugs, including tricyclics (such as
amitriptyline hydrochloride p. 372 and imipramine
hydrochloride p. 376 [unlicensed use]), duloxetine p. 367,
and venlafaxine p. 368 [unlicensed use] should be considered
in patients for the treatment of painful diabetic peripheral
neuropathy. Antiepileptic drugs, such as pregabalin p. 324
and gabapentin p. 315, can also be considered. Opioid
analgesics in combination with gabapentin can be
considered if pain is not controlled with monotherapy. h
In autonomic neuropathy, diabetic diarrhoea can often be
managed by tetracycline p. 567 [unlicensed use], or codeine
phosphate p. 454 as the best alternative; other
antidiarrhoeal preparations can also be tried. Erythromycin
p. 539 (especially when given intravenously) may be
beneficial for gastroparesis [unlicensed use].
In neuropathic postural hypotension, increased salt intake
and the use of the mineralcorticoid fludrocortisone acetate
p. 676 [unlicensed use] may help by increasing plasma
volume, but uncomfortable oedema is a common side-effect.
Fludrocortisone can also be combined with flurbiprofen
p. 1140 and ephedrine hydrochloride p. 272 [both
unlicensed]. Midodrine [unlicensed], an alpha agonist, may
also be useful in postural hypotension.
Gustatory sweating can be treated with an antimuscarinic
such as propantheline bromide p. 86; side-effects are
common. See also, the management of hyperhidrosis
In some patients with neuropathic oedema, ephedrine
hydrochloride [unlicensed use] offers effective relief.
See also the management of Erectile dysfunction p. 812.
g Optimal diabetic control (HbA1c ideally around 7% or
53 mmol/mol) and blood pressure control (<130/80 mmHg)
should be maintained to prevent onset and progression of
The management of diabetic ketoacidosis involves the
replacement of fluid and electrolytes and the administration
of insulin. Guidelines for the Management of Diabetic
Ketoacidosis in Adults, published by the Joint British
Diabetes Societies Inpatient Care Group (available at
www.diabetes.org.uk/Professionals/Position-statements-reports/
. To restore circulating volume if systolic blood pressure is
below 90 mmHg (adjusted for age, sex, and medication as
appropriate), give 500 mL sodium chloride 0.9% by
intravenous infusion over 10–15 minutes; repeat if blood
pressure remains below 90 mmHg and seek senior medical
. When blood pressure is over 90 mmHg, sodium chloride
0.9% should be given by intravenous infusion at a rate that
replaces deficit and provides maintenance; see guideline
. Include potassium chloride in the fluids unless anuria is
suspected; adjust according to plasma-potassium
concentration (measure at 60 minutes, 2 hours, and
2 hourly thereafter; measure hourly if outside the normal
. Start an intravenous insulin infusion: soluble insulin
should be diluted (and mixed thoroughly) with sodium
chloride 0.9% intravenous infusion to a concentration of
1 unit/mL; infuse at a fixed rate of 0.1 units/kg/hour.
. Established subcutaneous therapy with long-acting insulin
analogues (insulin detemir p. 717 or insulin glargine
p. 718) should be continued during treatment of diabetic
. Monitor blood-ketone and blood-glucose concentrations
hourly and adjust the insulin infusion rate accordingly.
Blood-ketone concentration should fall by at least
0.5 mmol/litre/hour and blood-glucose concentration
should fall by at least 3 mmol/litre/hour.
. Once blood-glucose concentration falls below
14 mmol/litre, glucose 10% should be given by
sodium chloride 0.9% infusion.
. Continue insulin infusion until blood-ketone
concentration is below 0.3 mmol/litre, blood pH is above
7.3 and the patient is able to eat and drink; ideally give
subcutaneous fast-acting insulin and a meal, and stop the
insulin infusion 1 hour later.
The management of hyperosmolar hyperglycaemic state or
hyperosmolar hyperglycaemic nonketotic coma is similar to
that of diabetic ketoacidosis, although lower rates of insulin
infusion are usually necessary and slower rehydration may
Management of diabetes during surgery
Peri-operative management of blood-glucose concentrations
depends on factors including the required duration of
fasting, timing of surgery (morning or afternoon), usual
treatment regimen (insulin, antidiabetic drugs or diet), prior
glycaemic control, other co-morbidities, and the likelihood
that the patient will be capable of self-managing their
diabetes in the immediate post-operative period.g All
patients should have emergency treatment for
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