What is the recommended management of stress hyperglycemia in adult hospitalized patients, including glucose monitoring frequency, target glucose range, insulin regimen, and criteria for de‑escalation?

Management of Stress Hyperglycemia in Hospitalized Adults

For adult hospitalized patients with stress hyperglycemia, initiate insulin therapy only when blood glucose is persistently ≥180 mg/dL on two separate measurements, targeting a glucose range of 140-180 mg/dL for most patients, using basal insulin with correction doses (or continuous IV insulin in the ICU), monitoring glucose every 4-6 hours initially, and planning outpatient follow-up within 1-2 weeks after discharge given the increased risk of developing diabetes. 1, 2, 3

Glucose Monitoring Frequency

• Check blood glucose every 4-6 hours initially for all hospitalized patients with stress hyperglycemia 2
• Increase monitoring frequency if glucose >250 mg/dL or <70 mg/dL 2
• In critically ill patients on continuous insulin infusion, glucose should be monitored hourly until stable, then every 2 hours 1, 3
• For patients on subcutaneous insulin regimens in non-critical care settings, point-of-care testing before meals and at bedtime is appropriate 1

Target Glucose Range

Non-Critically Ill Patients

• Target glucose 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of general medicine and surgical patients 1
• Premeal glucose target <140 mg/dL (7.8 mmol/L) and random glucose <180 mg/dL (10.0 mmol/L) 1
• More stringent goals of 110-140 mg/dL may be considered for select patients only if achievable without significant hypoglycemia 1

Critically Ill Patients (ICU)

• Target glucose 140-180 mg/dL (7.8-10.0 mmol/L) for most ICU patients 1, 3
• More stringent targets of 110-140 mg/dL may be appropriate for cardiac surgery patients if achievable without hypoglycemia 1, 3
• Never target 80-110 mg/dL as the NICE-SUGAR trial demonstrated this increases mortality and causes 10-15 fold higher rates of hypoglycemia 1, 2, 3

Insulin Regimen Selection

Critically Ill Patients (ICU Setting)

• Continuous IV insulin infusion is the preferred regimen for all ICU patients with persistent hyperglycemia ≥180 mg/dL 1, 3
• IV insulin has a short half-life (<15 minutes), allowing rapid dose adjustments with changes in clinical status or nutrition 1, 3
• Most protocols lower glucose to target range within 4-8 hours 1, 3
• Computer-based algorithms reduce hypoglycemia rates and improve time in target range 3
• Avoid subcutaneous insulin in critically ill patients, especially during hypotension or shock 1

Non-Critically Ill Patients

For patients with adequate oral intake:

• Basal insulin plus correction doses is the preferred regimen for most non-critically ill patients 1, 2
• Start with basal insulin at 0.2 units/kg/day for moderate hyperglycemia 1
• Add rapid-acting correction insulin before meals or every 6 hours 1
• For severe hyperglycemia (>300 mg/dL or 16.6 mmol/L), use basal-bolus regimen with half the total daily dose as basal and half as prandial insulin 1

For patients with poor or variable oral intake:

• Use basal insulin with correction doses only 1
• Avoid prandial insulin if nutritional intake is unpredictable 1

Critical pitfall: Never use sliding-scale insulin alone as monotherapy—it results in poor glycemic control, increased complications, and dangerous glucose fluctuations 1, 2, 3

Specific Clinical Scenarios

Mild Hyperglycemia (140-180 mg/dL)

• Observation and monitoring without active insulin treatment is appropriate for most patients 2
• Arrange outpatient follow-up within 1-2 weeks 2

Moderate Hyperglycemia (180-300 mg/dL)

• Recheck glucose in 2 hours to confirm persistent elevation before initiating insulin 2
• If persistently ≥180 mg/dL, start basal insulin at 0.2 units/kg/day with correction doses 1

Severe Hyperglycemia (>300 mg/dL)

• Initiate basal-bolus insulin regimen immediately 1
• Start total daily dose of 0.3-0.5 units/kg, divided half as basal and half as prandial 1

Steroid-Induced Hyperglycemia

• Insulin requirements may increase by 40-60% or more 3
• Use basal-bolus regimen for patients on high-dose steroids 1
• Consider continuous insulin infusion for severe cases 1

Criteria for De-escalation

Transitioning from IV to Subcutaneous Insulin

• Transition when patient is clinically stable and able to eat consistently 1
• Calculate total daily dose from the last 6-8 hours of IV insulin infusion 1
• Give first dose of basal insulin 2-3 hours before stopping IV insulin 1
• Continue glucose monitoring every 4-6 hours initially 2

Reducing Insulin Doses

• If hypoglycemia (<70 mg/dL) occurs, reduce the responsible insulin component by 20-50% 2
• For patients with improving clinical status and decreasing insulin requirements, reduce total daily dose by 10-20% every 1-2 days 1
• Consider discontinuing insulin if glucose consistently <140 mg/dL on minimal doses (<0.1 units/kg/day) 1

Discharge Planning

• Do not discharge patients on premixed insulin (70/30) due to unacceptably high hypoglycemia rates 2
• Arrange outpatient follow-up within 1-2 weeks as patients with stress hyperglycemia remain at increased risk for developing type 2 diabetes 2, 4, 5
• Measure HbA1c at discharge if not done in previous 3 months to assess pre-existing diabetes 1
• Provide diabetes self-management education including glucose monitoring, medication administration, and hypoglycemia recognition 1

Critical Safety Considerations

Hypoglycemia Prevention

• Ensure potassium ≥4.0 mEq/L before starting insulin therapy as hypoglycemia during treatment occurs in 50% of patients 2
• Severe hypokalemia (<2.5 mEq/L) is associated with increased mortality 1, 2
• Establish a hypoglycemia management protocol for all patients on insulin 2

Special Populations

• Elderly patients: Use lower insulin doses to prevent hypoglycemia 3
• Renal failure (CKD Stage 5): Reduce total daily insulin dose by 50% 3
• Patients on high-dose home insulin: Reduce total daily dose by 20% upon hospitalization 3

Common Pitfalls to Avoid

• Never target glucose <110 mg/dL outside highly selected populations 2, 3
• Avoid aggressive glucose lowering in acute myocardial infarction or stroke as intensive control increases hypoglycemia without mortality benefit 1, 2
• Do not use oral antidiabetic agents as primary therapy for stress hyperglycemia in acutely ill patients 1
• Never assume stress hyperglycemia equals diabetes—interpret glucose in context of acute illness and check HbA1c 1, 5