Inpatient glycemic management

Inpatient hyperglycemia is not merely a transient response to illness or stress, but a condition that requires active management.

In both critical and noncritical care settings, glycemic control should be individualized to the patient's clinical status and to the resources available.

In critically ill patients, the preferred approach is an intravenous insulin infusion accompanied by dextrose infusion. However, tight glycemic control within the normal range of 80-110 mg/dL (4.4 to 6.1 mmol/L) is not generally necessary and may even be harmful.

For noncritically ill hospitalized patients, a basal-bolus insulin or basal insulin regimen may be used. Sliding scale insulin alone should not be used in these patients, as it is less effective in achieving optimal glycemic control.

While management principles are similar for medical and surgical patients, hypoglycemia tends to occur more frequently in medical patients and is associated with poorer outcomes. As such, preventing hypoglycemia is a key priority in this population.

Both hyperglycemia and hypoglycemia are independently associated with increased mortality, regardless of a prior diagnosis of diabetes. Notably, patients with newly discovered hyperglycemia have significantly higher in-hospital mortality rates than those with a known history of diabetes or normal glucose levels.

Inpatient glycemic management refers to identifying and treating hyperglycemia in the setting of acute illness in hospitalized patients with either preexisting diabetes or new-onset hyperglycemia.​ This may occur in the intensive care unit or in the general floor, and evidence and guidelines differ between these settings.[1]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes Care. 2025 Jan 1;48(suppl 1):S1-352. https://diabetesjournals.org/care/issue/48/Supplement_1 [2]Diabetes Canada (Canadian Diabetes Association). Clinical practice guidelines for the prevention and management of diabetes in Canada. 2025 [internet publication]. https://guidelines.diabetes.ca/cpg [3]Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 2009 May-Jun;15(4):353-69. http://www.ncbi.nlm.nih.gov/pubmed/19454396?tool=bestpractice.com [4]Korytkowski MT, Muniyappa R, Antinori-Lent K, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2022 Jul 14;107(8):2101-28. https://academic.oup.com/jcem/article/107/8/2101/6605637 http://www.ncbi.nlm.nih.gov/pubmed/35690958?tool=bestpractice.com ​​ The three groups of patients to consider are the following: 1) known diabetes mellitus before admission; 2) new diagnosis of diabetes mellitus made on admission to the hospital (in these cases patients are not aware they have diabetes but present with hyperglycemia, and diabetes is diagnosed subsequently); 3) transient hyperglycemia (this may be related to stress, drug therapy such as corticosteroids, or parenteral and enteral nutrition, and resolves when the inciting factor is removed). The development of hyperglycemia during acute medical or surgical illness is not a physiologic or benign condition but is a marker of poor clinical outcome and increased mortality.[5]Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002 Mar;87(3):978-82. https://academic.oup.com/jcem/article/87/3/978/2846522 http://www.ncbi.nlm.nih.gov/pubmed/11889147?tool=bestpractice.com [6]Levetan CS, Magee MF. Hospital management of diabetes. Endocrinol Metab Clin North Am. 2000 Dec;29(4):745-70. http://www.ncbi.nlm.nih.gov/pubmed/11149160?tool=bestpractice.com [7]Finney SJ, Zekveld C, Elia A, et al. Glucose control and mortality in critically ill patients. JAMA. 2003 Oct 15;290(15):2041-7. https://jamanetwork.com/journals/jama/fullarticle/197458 http://www.ncbi.nlm.nih.gov/pubmed/14559958?tool=bestpractice.com

Hypoglycemia can be either iatrogenic or spontaneous, and can result from underlying medical illness, even in the absence of antidiabetic agents.[8]Hulkower RD, Pollack RM, Zonszein J. Understanding hypoglycemia in hospitalized patients. Diabetes Manag (Lond). 2014 Mar;4(2):165-76. https://pmc.ncbi.nlm.nih.gov/articles/PMC4153389 http://www.ncbi.nlm.nih.gov/pubmed/25197322?tool=bestpractice.com ​ The prevention and management of hypoglycemia in the inpatient setting is also addressed in this topic. Diabetic ketoacidosis and non-ketotic hyperosmolar hyperglycemia are not specifically addressed. See Diabetic ketoacidosis and Hyperosmolar hyperglycemic state.