Bedside Rounds

Hyperglycemia in hospitalized adults: workup and approach

Most non-critically ill hospitalized patients with diabetes or hyperglycemia should get scheduled basal (± prandial) insulin plus correction insulin, aiming for 140–180 mg/dL. Exclude DKA and HHS, avoid sliding-scale-only regimens, prevent hypoglycemia, and plan the discharge regimen early.

Presenting complaint Adult · US guidelines Draft · awaiting physician review
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01Orient

What's new in the evidence

  • ADA Standards of Care 2026 (Hospital section): target 140–180 mg/dL for most; check HbA1c if none in 3 months; CGM can be used in selected patients
  • Endocrine Society 2022 guideline: scheduled insulin over correction-only; prandial insulin when eating; NPH for glucocorticoid hyperglycemia
  • DPP-4 inhibitors with basal insulin are reasonable in mild hyperglycemia; SGLT2 inhibitors are usually held in acute illness (euglycemic DKA risk)

Differential diagnoses

  1. Known type 2 or type 1 diabetes
  2. Stress hyperglycemia (HbA1c <6.5%)
  3. Glucocorticoid-, TPN- or tube-feed–induced hyperglycemia
  4. DKA or HHS (can't miss)
  5. New diabetes, including pancreatogenic
  6. Infection driving hyperglycemia

02Assess

Risk scores and decision tools

  • Glucose targets: 140–180 mg/dL (110–140 in selected patients if achievable without hypoglycemia)
  • Hypoglycemia levels: level 1 <70, level 2 <54, level 3 = altered mental status
  • Weight-based total daily insulin: ~0.3 units/kg (older, CKD) to 0.5 units/kg

Key history questions

  • Diabetes type, home regimen, recent HbA1c
  • Oral intake: eating, NPO, tube feeds or TPN
  • Steroids and their timing
  • Kidney function, hypoglycemia history and awareness
  • Insulin pump or CGM use

Examination findings

  • Volume status
  • Mental status
  • Foot exam and infection sources

03Investigate

Initial investigations

  • Point-of-care glucose before meals and at bedtime (every 4–6 hours if NPO)
  • HbA1c if none in past 3 months
  • BMP; anion gap and ketones if glucose >250 mg/dL or type 1 diabetes

Advanced investigations

  • C-peptide and antibodies if type 1 suspected
  • Lipase if pancreatogenic

04Treat

Immediate management

  • Glucose >250 with acidosis or high anion gap: manage as DKA
  • Hypoglycemia <70 mg/dL: 15–20 g fast carbohydrate or IV dextrose; review the regimen

First-line treatment

  • Eating: basal-bolus (half basal glargine/detemir, half prandial split between meals) plus correction insulin
  • Poor intake or NPO: basal (reduce home dose 20–25%) plus correction insulin
  • Glucocorticoid hyperglycemia: NPH given with the morning steroid dose (~0.1 units/kg per 10 mg prednisone, up to 0.4 units/kg)
  • Type 1 diabetes: never stop basal insulin

Second-line treatment

  • Mild hyperglycemia in type 2: DPP-4 inhibitor plus basal insulin
  • Continuous tube feeds: basal plus regular insulin every 6 hours or NPH every 8–12 hours
  • Critical illness: IV insulin infusion, target 140–180 mg/dL

Specialist referrals

  • Inpatient diabetes team for uncontrolled glucose, type 1 diabetes, pumps
  • Diabetes education before discharge

05Disposition

Admission criteria

  • Hyperglycemia is rarely the sole reason; admit for DKA, HHS or severe symptomatic hyperglycemia

Safe discharge criteria

  • Stable regimen the patient can manage
  • Supplies, glucometer and teaching provided; follow-up in 1–2 weeks

Follow-up timing

  • Primary care or endocrinology within 1–4 weeks

Patient instructions

  • Hypoglycemia recognition and treatment
  • Sick-day rules (hold SGLT2 inhibitors and metformin when not eating)

Monitoring

  • Adjust insulin daily by 10–20% based on patterns
  • Reduce doses as steroids taper

Clinical pearls and pitfalls

  • Sliding-scale-only insulin is associated with worse control (RABBIT 2)
  • Hold most oral agents in acute illness; metformin with contrast or AKI
  • Use the HbA1c to choose the discharge regimen

RefGuidelines and landmark evidence

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.

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