Should hyperglycemia be treated in the acute setting?

From the Guidelines

In the acute setting, you should treat high glucose levels (hyperglycemia) when they exceed 180 mg/dL, particularly in critically ill patients. The primary treatment is insulin therapy, typically starting with an IV insulin infusion at 0.05-0.1 units/kg/hour for severe hyperglycemia, adjusting based on hourly glucose measurements 1. For less severe cases, subcutaneous rapid-acting insulin (like lispro, aspart, or glulisine) at 0.1 units/kg can be given. Always check glucose levels before meals and at bedtime, aiming for target ranges of 140-180 mg/dL in critically ill patients and 100-180 mg/dL in stable patients 1.

Key Considerations

• Identify and address the underlying cause of hyperglycemia, such as infection, medication effects, or diabetic ketoacidosis.
• Maintain adequate hydration with IV fluids if needed, and monitor electrolytes, particularly potassium, as insulin therapy can cause hypokalemia.
• Treating acute hyperglycemia is crucial because it reduces the risk of complications like impaired immune function, increased infection risk, poor wound healing, and metabolic derangements.
• However, avoid aggressive correction that might cause hypoglycemia, which can be more immediately dangerous than moderate hyperglycemia 1.

Target Glucose Ranges

• Critically ill patients: 140-180 mg/dL
• Stable patients: 100-180 mg/dL
• Selected patients (e.g., critically ill postsurgical patients or patients with cardiac surgery): 110-140 mg/dL, if achievable without significant hypoglycemia 1.

Recent Evidence

The most recent study from 2025 1 supports the initiation of insulin therapy for persistent hyperglycemia ≥180 mg/dL and recommends a glycemic goal of 140-180 mg/dL for most critically ill individuals with hyperglycemia. This study also highlights the importance of avoiding aggressive correction that might cause hypoglycemia.

From the FDA Drug Label

• Administer Insulin Aspart intravenously only under medical supervision with close monitoring of blood glucose and potassium levels to avoid hypoglycemia and hypokalemia [see Warnings and Precautions (5.3,5.6) and How Supplied/Storage and Handling (16.2)]. • Individualize the dosage of Insulin Aspart based on the route of administration, the patient’s metabolic needs, blood glucose monitoring results and glycemic control goal. • Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness [see Warnings and Precautions (5.2,5.3) and Use in Specific Populations (8.6,8.7)].

Treating high glucose in the acute setting requires close monitoring and individualized dosage adjustments.

• Intravenous administration of Insulin Aspart can be used under medical supervision to manage high glucose levels.
• Dosage adjustments should be made based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal.
• Close monitoring of blood glucose and potassium levels is necessary to avoid hypoglycemia and hypokalemia 2.

From the Research

Treatment of High Glucose in Acute Setting

• High glucose levels in the acute setting are associated with increased risk of hospital complications, higher healthcare resource utilization, and higher in-hospital mortality rates 3, 4.
• Appropriate glycemic control strategies can reduce these risks, although hypoglycemia is a concern 3.
• The target blood glucose level in the acute setting is between 140 and 180 mg/dL 3, 5.

Glycemic Control Strategies

• In critically ill patients, intravenous (IV) insulin is most appropriate, with a starting threshold no higher than 180 mg/dL 3.
• In noncritically ill patients, basal-bolus regimens with basal, prandial, and correction components are preferred for those with good nutritional intake 3, 6.
• A single dose of long-acting insulin plus correction insulin is preferred for patients with poor or no oral intake 3.
• Sliding-scale insulin regimens are not recommended due to the increased risk of hypoglycemia and large fluctuations in blood glucose levels 6, 5.

Insulin Therapy

• Insulin dosing depends on the patient's previous experience with insulin, baseline diabetes control, and renal function 5.
• Many patients can be managed using only a basal insulin dose, whereas others benefit from additional short-acting premeal doses 5.
• Continuous intravenous (i.v.) insulin therapy or intermittent subcutaneous (s.c.) basal-bolus plus correction injections is preferred 6.

Discharge Planning

• Discharge planning is an important opportunity to address diabetes control, medication adherence, and outpatient follow-up 5.
• Measuring hemoglobin A1c at admission is important to assess glycemic control and to tailor the treatment regimen at discharge 3.