Endocrinology · ADA

Inpatient hyperglycaemia management

ADA

Source:ADA Standards of Care in Diabetes 2026 — Section 16: Diabetes Care in the Hospital

Verified Apr 2026

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Red Flags

Severe hypoglycaemia (<54 mg/dL or 3.0 mmol/L) — IV dextrose 25 g; identify and address cause; review insulin orders^[1]
DKA: glucose >250, ketones positive, pH <7.3, HCO₃ <15 — ICU/HDU; IV insulin infusion, fluid resuscitation, electrolyte correction^[1]
HHS: glucose >600, osmolality >320 — IV fluids, slow glucose correction, careful sodium and potassium replacement^[1]
Persistent inpatient hyperglycaemia >180 mg/dL on sliding-scale-only regimen — escalate to basal-bolus; sliding-scale alone is discouraged^[1]

First-line treatment

Interventions

Glucose target 140–180 mg/dL in critical care; 100–180 mg/dL in non-critical wards^[1]
Tighter targets (110–140) only when achievable without significant hypoglycaemia. Avoid both ends of the spectrum
Hold metformin and sulphonylureas at admission^[1]
Metformin held with contrast, AKI, hypoperfusion. Sulphonylureas held with NPO status. Restart on discharge per renal function and oral intake
Hold SGLT2 inhibitors with acute illness^[1]
Risk of euglycaemic DKA; resume only after stable, eating, and not at risk of dehydration

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Basal-bolus insulin (basal + prandial + correction)^[1]	Subcutaneous insulin regimen	Total daily dose 0.3–0.5 U/kg; 50% basal (glargine, detemir, degludec), 50% prandial (lispro, aspart, glulisine) split across meals; correction doses for hyperglycaemia	—	Preferred for hospitalised T2DM not on SGLT2; sliding-scale-only discouraged
Insulin infusion (IV)^[1]	Continuous IV regular insulin	0.1 U/kg/h titrated to glucose 140–180 mg/dL in critical care	—	ICU hyperglycaemia, DKA, HHS, peri-operative critical illness, post-cardiac surgery
Long-acting basal insulin (degludec, glargine U-300)^[1]	Long-acting analogue	Once-daily; convert from infusion at 60–80% of last 6-h infusion rate × 4	—	Lower hypoglycaemia risk than NPH; transition off IV infusion to subcutaneous

Basal-bolus insulin (basal + prandial + correction)^[1]

Subcutaneous insulin regimen

Adult: Total daily dose 0.3–0.5 U/kg; 50% basal (glargine, detemir, degludec), 50% prandial (lispro, aspart, glulisine) split across meals; correction doses for hyperglycaemia
Paediatric: —

Preferred for hospitalised T2DM not on SGLT2; sliding-scale-only discouraged

Insulin infusion (IV)^[1]

Continuous IV regular insulin

Adult: 0.1 U/kg/h titrated to glucose 140–180 mg/dL in critical care
Paediatric: —

ICU hyperglycaemia, DKA, HHS, peri-operative critical illness, post-cardiac surgery

Long-acting basal insulin (degludec, glargine U-300)^[1]

Long-acting analogue

Adult: Once-daily; convert from infusion at 60–80% of last 6-h infusion rate × 4
Paediatric: —

Lower hypoglycaemia risk than NPH; transition off IV infusion to subcutaneous

Safety-net

Inform discharge clinician of any new insulin regimen; outpatient titration follow-up needed within 1–2 weeks^[1]
Carry emergency glucose source (juice, sweets) home; recognise early hypoglycaemia symptoms^[1]
If you missed your usual diabetes medications during admission, restart them carefully — confirm timing with discharge team^[1]

Referral criteria

DKA or HHSICU/HDU for IV insulin infusion and electrolyte management^[1]
Type 1 DM admission of any causeInpatient diabetes team within 24 h^[1]
Persistent inpatient hyperglycaemia >180 mg/dL despite escalationEndocrinology / inpatient diabetes service^[1]
New diagnosis of diabetes during admissionOutpatient endocrinology or primary care follow-up within 4 weeks of discharge^[1]

Clinical summary

Glycaemic targets and insulin protocols for hospitalised adults with diabetes or stress hyperglycaemia, separated for critical and non-critical care.

References

1.ADA Standards of Care in Diabetes 2026 — Section 16: Diabetes Care in the Hospital (2026)

Drug

Class

Adult

Paediatric

Notes