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.