Endocrine · Topic 4 of 13

Inpatient Hyperglycemia & Insulin Management

Endocrine · hospital glucose management

Inpatient Hyperglycemia & Insulin Management

Start insulin at glucose ≥ 180, aim for 140–180, use basal-bolus-correction insulin — never correction alone.

Key numbers

Start insulin at glucose ≥ 180 mg/dL≥ 180 mg/dL

Target 140–180 mg/dL in the ICU140–180 mg/dL

IV-to-SC: basal insulin 2 h before stoppingbasal 2 h before stop

Starting dose 0.5–0.6 U/kg/day; 0.3 if frail0.3–0.6 U/kg/day

TPN: regular insulin in the bag1 U per 10 g dextrose

01 · Defined byStart insulin at glucose ≥ 180 mg/dL

Start insulin for persistent hyperglycemia at ≥ 180 mg/dL, confirmed twice within 24 hours, in both critically and noncritically ill patients.

02 · The numberTarget 140–180 mg/dL in the ICU

Glucose goal: 140–180 mg/dL for most critically ill patients; 100–180 mg/dL for noncritically ill patients if reachable without significant hypoglycemia (Endocrine Society, ADA).

03 · DoBasal-bolus-correction, never correction alone

A plan with basal, prandial and correction insulin is preferred for patients who are eating; correction (sliding-scale) insulin without basal insulin is discouraged for most inpatients.

Diagnosis & monitoring

Work-up

Order an A1C if none in 3 monthsCheck A1C on admission in everyone with diabetes or hyperglycemia unless one was done in the past 3 months; it separates stress hyperglycemia from undiagnosed diabetes and guides the discharge regimen.

POC glucose before meals, or every 4–6 hCheck point-of-care glucose before meals in patients who eat and every 4–6 hours in those who are NPO or on continuous feeds; confirm CGM readings with POC values before dosing.

Perioperative glucose 100–180 mg/dLKeep glucose 100–180 mg/dL within 4 hours of surgery, and aim for a preoperative A1C < 8% before elective surgery whenever possible.

Management

Orders

IV-to-SC: basal insulin 2 h before stopping must knowGive subcutaneous basal insulin about 2 hours before stopping an insulin infusion; estimate the total daily dose from weight, the home regimen or the infusion's hourly requirement, allowing for nutrition and steroids.

ICU: continuous IV insulin infusionIn critical illness, a validated continuous IV insulin infusion protocol is the most effective way to reach the 140–180 mg/dL goal.

Starting dose 0.5–0.6 U/kg/day; 0.3 if frailA weight-based starting total daily dose is about 0.5–0.6 U/kg/day for insulin-naive patients and about 0.3 U/kg/day for older, frail or kidney-impaired patients, given as basal plus prandial insulin.

Steroid hyperglycemia: NPH with the morning doseMorning prednisone raises afternoon and evening glucose while fasting glucose stays near normal; give NPH with the steroid dose, weight-based (up to about 0.4 U/kg), and taper it with the steroid.

Tube feeds: basal plus scheduled nutritional insulinFor continuous enteral feeds, continue basal insulin and add nutritional insulin, about 1 unit per 10–15 g carbohydrate, as regular insulin every 6 h or rapid-acting every 4 h; stop if feeds stop.

TPN: regular insulin in the bagFor parenteral nutrition, regular insulin can be added to the TPN bag, starting at 1 unit per 10 g dextrose, with correction insulin on top.

Before surgery: cut basal insulin 20–25%The night before surgery give 75–80% of the usual long-acting basal insulin dose (NPH: half); hold oral agents the morning of surgery and SGLT2 inhibitors 3–4 days before.

Mild hyperglycemia: DPP-4 inhibitor ± basalFor mild-to-moderate hyperglycemia in type 2 diabetes, a DPP-4 inhibitor with or without basal insulin is a safer, simpler alternative to basal-bolus insulin.

Red flags & don'ts

Avoid harm

No SGLT2 inhibitors for inpatient glucose control avoidSGLT2 inhibitors are not recommended for inpatient glycemic management and are avoided in severe illness, ketosis, prolonged fasting and surgery; they may continue in stable heart-failure admissions.

The rules

Know these

Type 1 diabetes always keeps basal insulinPatients with type 1 diabetes must continue basal insulin even when NPO or when feeds stop — without it they develop DKA.

Basal-bolus or correction-only insulin?

Commonly confused

ADA status	Preferred plan
Covers	Basal needs, meals and highs
Type 1 diabetes	Basal always continued

More detail

Reference

Show 3 reference facts

A tighter 110–140 mg/dL range may suit selected critically ill patients, only if achievable without significant hypoglycemia.

Patients able to manage their own insulin pump and CGM may continue them in hospital under institutional protocols, with POC confirmation for dosing.

Base the discharge regimen on the admission A1C, prior medications and inpatient insulin needs; this approach improves A1C after discharge.

Pearl

Sliding scale alone treats yesterday’s glucose; basal insulin prevents tomorrow’s.

Sources · ADA. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl 1) · Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (ADA/EASD/JBDS/AACE/DTS). Diabetes Care 2024;47:1257–1275, doi:10.2337/dci24-0032 (open copy read: Diabetologia 2024;67:1455–1479, PMC11343900) · Aberer F et al. A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital. J Clin Med 2021;10:2154 · CMS eCQM CMS871 Hospital Harm—Severe Hyperglycemia (quotes ADA Standards 2024 recs 16.4–16.5 and the 2022 Endocrine Society non-critical-care guideline) · Bahendeka S et al. EADSG Guidelines: Insulin Therapy in Diabetes. Diabetes Ther 2018;9:449–492 (Table 9, enteral/parenteral insulin adapted from ADA) · Preoperative Diabetes Management for Patients Undergoing Elective Surgeries at a Veterans Affairs Medical Center. Fed Pract / The Hospitalist (cites ADA Standards 2025 perioperative goals) · Diabetes Education Services. Rationale of the Week: Safe for Surgery (ADA perioperative basal-insulin and oral-agent guidance) · Pros and Cons of Inpatient SGLT2i Use for Hyperglycemia and Heart Failure. J Endocr Soc 2025 · In-Hospital Management of Hyperglycemia: The Role of Insulin Degludec. Diabetes Ther 2025 (summarizes ADA hospital recommendations) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).