Inpatient management of hyperglycemia

Last updated: June 29, 2023

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Summarytoggle arrow icon

Hyperglycemia is a common occurrence in hospitalized patients and for inpatients is defined as a blood glucose (BG) level > 140 mg/dL. Common causes of hyperglycemia in hospitalized patients include underlying diabetes mellitus, medications (e.g., corticosteroids, thiazide diuretics), parenteral nutrition, and stress (e.g., due to surgery, trauma, or sepsis). Regardless of the cause, hyperglycemia is associated with longer hospital stays and worse outcomes. A structured, methodical approach to hyperglycemia is key to good glycemic control in hospitalized patients. When managing blood sugar levels, special care should be taken to avoid potentially life-threatening hypoglycemia, which can occur as a complication of insulin therapy. For more information, see diabetes mellitus and insulin.

Clinical approachtoggle arrow icon

  1. Rule out hyperglycemic crises.
  2. Identify (and treat) the underlying cause.
  3. Determine whether to initiate insulin therapy.
    • Insulin therapy is generally recommended for persistently elevated glucose ≥ 180 mg/dL. [2]
    • The goal is moderate glycemic control (glucose range: 140–180 mg/dL). [2][3]
  4. Start an appropriate insulin regimen, if indicated (see insulin regimens).
  5. Monitor and adjust therapy as needed:
  6. Avoid (and treat) hypoglycemia (generally defined as ≤ 70 mg/dL, see hypoglycemia). [2]
  7. Consider endocrine consult or hyperglycemia team consult if glucose is difficult to control.

Hyperglycemic crisis (DKA and HHS) must be ruled out in all hyperglycemic patients.

Target glucose may vary depending on individual patient factors (e.g., more liberal goals for terminally ill patients may be acceptable).

Patients with underlying diabetes mellitustoggle arrow icon

Critically-ill patients in the intensive care unittoggle arrow icon

  • Indication for insulin therapy: blood glucose > 180 mg/dL [2]
  • Recommended insulin regimen
    • Continuous intravenous insulin infusion (IIP) is preferable. [2][8]
    • Avoid IIP in the following situations:
      • Rapid normalization of glucose expected
      • Patients close to transfer to a general ward
      • Terminally-ill patients
      • Patients who are eating
    • For patients not on IIP, a basal-bolus insulin regimen is usually appropriate
  • Monitoring: POC glucose hourly, if on a continuous insulin infusion
  • Other considerations: Ideal glucose targets for critically ill patients are still under discussion.

Glucocorticoid-induced hyperglycemiatoggle arrow icon

An individual approach is necessary. For example, a patient with mild hyperglycemia who is on a low dose of glucocorticoids that is being tapered will require a different approach than a patient with glucose levels > 300 mg/dL on chronic high-dose glucocorticoids.

Hyperglycemia during enteral or parenteral nutritiontoggle arrow icon

Patients with type 1 diabetes mellitus require basal insulin even if (enteral) feeding is discontinued.

Other special patient groupstoggle arrow icon

Stress-induced hyperglycemia

  • Many stressors can cause hyperglycemia (e.g., ACS, trauma, surgery). [10]
  • Attempts should be made to identify and treat the underlying stressor.
  • Glycemic management is otherwise similar to standard diabetes care (see “Patients with underlying diabetes mellitus” above).

Drug-induced hyperglycemia [11][12][13]

Patients on continuous subcutaneous insulin infusion (CSII) [14]

  • CSII (i.e., insulin pump) is usually discontinued when patients are admitted to the hospital.
  • Continuation of CSII may be considered in select patients if:
    • The patient demonstrates the capacity to use the pump correctly.
    • No contraindications for CSII are present, e.g.:
      • Patient unable to participate actively in blood sugar management
      • An altered state of consciousness
      • DKA
      • Severe illness (e.g., sepsis)
      • Need for MRI
      • Suicidal ideation
  • If CSII is discontinued, a basal-bolus insulin regimen is recommended.

Every patient switched from continuous subcutaneous insulin infusion to another insulin regimen should receive basal insulin.

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Acute management checklisttoggle arrow icon

Referencestoggle arrow icon

  1. Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, et al.. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2023. Diabetes Care. 2022; 46 (Supplement_1): p.S267-S278.doi: 10.2337/dc23-s016 . | Open in Read by QxMD
  2. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care. 2009; 32 (6): p.1119-1131.doi: 10.2337/dc09-9029 . | Open in Read by QxMD
  3. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2012; 97 (1): p.16-38.doi: 10.1210/jc.2011-2098 . | Open in Read by QxMD
  4. Gosmanov AR, Umpierrez GE. Management of Hyperglycemia During Enteral and Parenteral Nutrition Therapy. Curr Diab Rep. 2012; 13 (1): p.155-162.doi: 10.1007/s11892-012-0335-y . | Open in Read by QxMD
  5. Bogun M, Inzucchi SE. Inpatient Management of Diabetes and Hyperglycemia. Clin Ther. 2013; 35 (5): p.724-733.doi: 10.1016/j.clinthera.2013.04.008 . | Open in Read by QxMD
  6. Fathallah N, Slim R, Larif S, Hmouda H, Ben Salem C. Drug-Induced Hyperglycaemia and Diabetes. Drug Safety. 2015; 38 (12): p.1153-1168.doi: 10.1007/s40264-015-0339-z . | Open in Read by QxMD
  7. Jain V, Patel RK, Kapadia Z, Galiveeti S, Banerji M, Hope L. Drugs and hyperglycemia: A practical guide. Maturitas. 2017; 104: p.80-83.doi: 10.1016/j.maturitas.2017.08.006 . | Open in Read by QxMD
  8. Rehman A, Setter SM, Vue MH. Drug-Induced Glucose Alterations Part 2: Drug-Induced Hyperglycemia. Diabetes Spectrum. 2011; 24 (4): p.234-238.doi: 10.2337/diaspect.24.4.234 . | Open in Read by QxMD
  9. Thompson B, Korytkowski M, Klonoff DC, Cook CB. Consensus Statement on Use of Continuous Subcutaneous Insulin Infusion Therapy in the Hospital. Journal of Diabetes Science and Technology. 2018; 12 (4): p.880-889.doi: 10.1177/1932296818769933 . | Open in Read by QxMD
  10. Umpierrez GE, Smiley D, Zisman A, et al. Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial). Diabetes Care. 2007; 30 (9): p.2181-2186.doi: 10.2337/dc07-0295 . | Open in Read by QxMD
  11. Roberts GW, Aguilar‐Loza N, Esterman A, Burt MG, Stranks SN. Basal–bolus insulin versus sliding‐scale insulin for inpatient glycaemic control: a clinical practice comparison. Med J Aust. 2012; 196 (4): p.266-269.doi: 10.5694/mja11.10853 . | Open in Read by QxMD
  12. Kitabchi AE, Nyenwe E. Sliding-Scale Insulin: More evidence needed before final exit?. Diabetes Care. 2007; 30 (9): p.2409-2410.doi: 10.2337/dc07-1141 . | Open in Read by QxMD
  13. Dunaif A. Insulin Resistance and the Polycystic Ovary Syndrome: Mechanism and Implications for Pathogenesis. Endocr Rev. 1997; 18 (6): p.774-800.doi: 10.1210/edrv.18.6.0318 . | Open in Read by QxMD
  14. $Contributor Disclosures - Inpatient management of hyperglycemia. All of the relevant financial relationships listed for the following individuals have been mitigated: Joanna Jan (medical editor, is an independent contractor for GoodRx, and is a shareholder in GoodRx, Biocept, and Rite Aid). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  15. NICE-SUGAR Study Investigators. Intensive versus Conventional Glucose Control in Critically Ill Patients. N Engl J Med. 2009; 360 (13): p.1283-1297.doi: 10.1056/nejmoa0810625 . | Open in Read by QxMD
  16. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009; 32 (7): p.1335-1343.doi: 10.2337/dc09-9032 . | Open in Read by QxMD
  17. American Diabetes Association. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2017; 41 (Supplement 1): p.S144-S151.doi: 10.2337/dc18-s014 . | Open in Read by QxMD
  18. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes. The Journal of Clinical Endocrinology & Metabolism. 2002; 87 (3): p.978-982.doi: 10.1210/jcem.87.3.8341 . | Open in Read by QxMD
  19. Donihi et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Quality and Safety in Health Care. 2006; 15 (2): p.89-91.doi: 10.1136/qshc.2005.014381 . | Open in Read by QxMD
  20. Shetty S, Inzucchi SE, Goldberg PA, Cooper D, Siegel MD, Honiden S. Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: the updated Yale insulin infusion protocol.. Endocr Pract. 2012; 18 (3): p.363-70.doi: 10.4158/EP11260.OR . | Open in Read by QxMD
  21. Kwon S, Hermayer KL, Hermayer K. Glucocorticoid-Induced Hyperglycemia. Am J Med Sci. 2013; 345 (4): p.274-277.doi: 10.1097/maj.0b013e31828a6a01 . | Open in Read by QxMD

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