Insulin Management in the Inpatient Setting: A Comprehensive Review

Abstract

Abstract

Effective inpatient insulin management is a critical component of hospital medicine, aiming to maintain glycemic control, reduce complications, and optimize patient outcomes. Hyperglycemia, defined as a blood glucose greater than 140 mg/dL, is reported in 22–46% of non-critically ill hospitalized patients and is independently associated with increased mortality, infection, prolonged length of stay, and readmission. This comprehensive review synthesizes current evidence-based strategies and updated guideline recommendations — including the 2025 American Diabetes Association Standards of Care and the 2022 Endocrine Society Clinical Practice Guideline — for managing insulin across the inpatient spectrum. The review outlines insulin pharmacokinetics, dosing methodologies including basal-bolus regimens and correction-scale protocols, and specific considerations for special populations such as critically ill, perioperative, glucocorticoid-treated, and total parenteral nutrition (TPN) patients. It addresses the updated consensus on diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) management, the impact of concurrent non-insulin medications including emerging data on SGLT2 inhibitors and GLP1 receptor agonists in the inpatient setting, and practical protocols for transitioning between intravenous and subcutaneous insulin. The paper also addresses emerging technologies, including continuous glucose monitoring (CGM) in the hospital, and the importance of structured discharge planning for glycemic continuity. The overarching goal is to provide hospital-based clinicians with a concise yet comprehensive reference to guide safe and effective inpatient insulin therapy.