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Raised Blood Glucose in Known Diabetes – Primary Care Triage Tool

Raised blood sugar in patients with known diabetes is a frequent challenge in primary care, requiring prompt and systematic assessment to prevent acute complications such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) while addressing chronic control. As primary care clinicians, you often encounter these cases in triage settings with limited access to full patient records, relying on recent results (e.g., HbA1c, prior glucose readings, out-of-hours encounters) to guide decisions.


This stepwise triage guide provides a structured approach to evaluate and manage elevated blood glucose levels, using both mmol/L and mg/dL units for clarity. It emphasizes identifying urgent cases, leveraging available data, and ensuring patient safety through timely intervention and clear follow-up. The following steps aim to balance efficiency with thoroughness, enabling you to differentiate between routine hyperglycemia and emergencies while supporting patient education and continuity of care.



🧪 Step 1: Confirm Blood Glucose & Measurement

Q: What is the patient's current blood glucose level and how was it measured (fingerstick/lab)?

  • Mild: 7.8–11.1 mmol/L (140–200 mg/dL)
  • Moderate: 11.2–16.7 mmol/L (201–300 mg/dL)
  • Severe: >16.7 mmol/L (>300 mg/dL)

Action: If no recent reading, request a capillary test. >22.2 mmol/L (>400 mg/dL) may indicate acute risk.

🚨 Step 2: Assess for Acute Symptoms & Ketones

Q: Symptoms: Nausea, vomiting, breathlessness, confusion?

  • Type 1: >13.9 mmol/L (>250 mg/dL) with illness or symptoms
  • Type 2: >16.7 mmol/L (>300 mg/dL) with symptoms or illness
  • Any type: >18 mmol/L (>324 mg/dL) regardless of symptoms

Action: Check capillary blood ketones or urine. If >1.5 mmol/L or urine moderate/large → urgent ED referral.

📊 Step 3: HbA1c & Trend Review

Q: Recent HbA1c and blood glucose trends?

  • Good control: HbA1c <7% (<53 mmol/mol)
  • Poor control: HbA1c >9% (>75 mmol/mol)

Action: If not available, use current CBG + symptoms to guide triage.

💊 Step 4: Medication Adherence

Q: Missed any meds (e.g., insulin, metformin)? Started steroids?

  • Missed insulin → DKA risk
  • Steroids → may cause hyperglycemia

Action: Resume meds if appropriate. Adjust insulin doses in consultation.

📍 Step 5: Identify Triggers

Q: Infection? High-carb intake? Stress? Reduced activity?

Action: Treat cause. Reinforce hydration, monitoring, and sick-day rules.

⚠️ Step 6: Comorbidities & Complications

Q: History of retinopathy, nephropathy, CVD, or HF?

Action: Escalate earlier if comorbid or vulnerable.

🧭 Step 7: Triage Plan

  • Emergency: >22.2 mmol/L (>400 mg/dL) + symptoms or ketones ≥3 mmol/L
  • Urgent: 11.2–22.2 mmol/L (201–400 mg/dL) + mild symptoms
  • Routine: 7.8–11.1 mmol/L (140–200 mg/dL), stable

Action: Escalate appropriately. Adjust meds or monitor at home with follow-up.

📘 Step 8: Patient Advice & Follow-Up

Q: Does the patient understand how to monitor, hydrate, and when to seek help?

  • Check CBG every 4–6 hrs if elevated
  • Hydrate well; avoid sugary drinks
  • Ketones >1.5 mmol/L = seek urgent care

Action: Book GP/diabetes nurse f/u in 48–72 hrs. Document advice.



PRN insulin use for raised blood glucose in clinically well patients with diabetes.


💉 PRN Insulin Use in Clinically Well Diabetic Patients – Stepwise Guide

✅ Step 1: Define the Target Range

Patient Group CBG Target (mmol/L) CBG Target (mg/dL)
Standard Adult 6–10 108–180
Frail / Elderly / EoL 6–15 108–270


⚠️ Step 2: Determine PRN Dose Eligibility

  • Only consider PRN insulin if CBG >18.0 mmol/L (>324 mg/dL)

  • Assess individual risk: frailty, insulin sensitivity, current regimen

  • Avoid bedtime PRNs in elderly (higher hypoglycemia risk)



💉 Step 3: PRN Insulin Dose Table

CBG (mmol/L) CBG (mg/dL) Suggested PRN Dose
18.1 – 25.0 325 – 450 4 units Novorapid® / Trurapi® (subcut)
≥ 25.1 ≥ 451 6 units Novorapid® / Trurapi® (subcut)

  • Dose reduction (e.g., 2–4 units) advised for frail or insulin-sensitive patients

  • Expected glucose drop: ~3 mmol/L (~54 mg/dL) per unit



🔁 Step 4: Monitor Response

  • Check capillary blood glucose:

    • 2 hours post-PRN dose

    • 4 hours post-PRN dose



🔄 Step 5: Review PRN Use Over 48 Hours

PRN Use Over 48 Hours Recommended Action
No doses required 🛑 Stop PRN insulin
1 dose given ✅ Continue PRN, review daily
≥2 doses given ⚠️ Review insulin plan; consider titration or specialist input


Final Reminders

  • Always consider patient context before prescribing PRN insulin.

  • Document indication, dose, and timing clearly.

  • Liaise with diabetes specialist if frequent corrections are needed.

Let me know if you'd like this formatted for print or integrated into a patient safety checklist.



References