Type 2 diabetes mellitus (T2DM) is a frequent comorbidity in hospitalized patients, and its management requires an individualized approach. article presents a series of cases clinical complex that illustrate the therapeutic approach to hyperglycemia in different hospital settings. In each case HE they analyze the implications The pathophysiological processes, associated risks, and recommended pharmacological strategies according to the 2025 ADA guidelines and the most recent evidence are discussed. The importance of avoiding hypoglycemia, adjusting insulin regimens, and selecting drugs with proven cardiovascular and renal benefits is also addressed.

Hospitalization of patients with type 2 diabetes offers an opportunity to optimize glycemic treatment and reassess risks, comorbidities, and treatment regimens. therapeutic. He around hospitable is dynamic and complex, This necessitates rapid but well-founded therapeutic decisions, especially when hyperglycemia coexists with other critical conditions. [24]. The hyperglycemia hospital No only worsens he forecast, but that HE ha associated with elderly mortality, infections nosocomial infections, prolonged stay, and cardiovascular complications. [25,26]

Glycemic control should prioritize safety, avoiding hypoglycemia, especially in frail or polymedicated patients. Treatment selection should consider the extra-pancreatic benefits of newer antidiabetic drugs, such as GLP- 1 analogues and SGLT2 inhibitors, which have been shown to improve cardiovascular and renal outcomes, even beyond glycemic control. [1,2]

Clinical situations such as steroid use, enteral or parenteral nutrition, acute coronary syndromes, or advanced kidney disease require therapeutic decisions that go beyond the conventional algorithm. This article presents a series of representative clinical cases. of these scenarios, directed to professionals of health with training clinic, with he aim of integrate the pathophysiology, the pharmacological evidence and personalized decision-making in the hospital setting.

According to the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE), hyperglycemia in patients hospitalized HE define as a concentration of glucose In blood ≥140 mg/dl, once this alteration is documented, hbA1c (glycated hemoglobin) should be measured to differentiate stress-induced hyperglycemia vs. de novo diagnosis of diabetes mellitus [4].

Glycemic targets may vary according to clinical conditions and the recommendations of different guidelines. According to the ADA for hospitalized patients critics and No, he aim glycemic is of 100 – 180 mg/dl, In patients with terminal illnesses, acceptable values are suggested >250 mg/dl. [3]

Previously, it was thought that with stricter glycemic control, could impact in outcomes clinical as the mortality, without embargo by half of studies as he NICE SUGAR HE demonstrated that he control stricter blood glucose (81-108 mg/dl) is associated with a higher mortality rate after of 90 days and increase in he risk of hypoglycemia. [27]

HE performed the description of 4 cases clinical taken of the life real with the objective of illustrating the approach and The treatment of hyperglycemia in hospitalized patients, individualizing each case according to pre-existing conditions and taking into account the therapeutic challenges that arise throughout hospitalization

Terms of search

To guide each search, keywords were used, initially searched in the Health Sciences Descriptors (DeCS) and then in The terms were Medical Subject Headings (MeSH terms). DeCS terms were used for searches in ClinicalKey and LILACS, while MeSH terms were used in Medline and Embase.

Criteria of selection

Inside of the criteria of selection of the articles, HE included primary studies and those with secondary evidence of the review type (both systematic as narrative). The search HE limited to publications of the last 30 years (1994 to 2024). No language restrictions were imposed. The selected articles were downloaded for reading They were completed and discussed with the main course author to assess their quality before being included as bibliographic references.

Results And Discussion

Revision Of Cases Clinicians

Case Clinical 1

A 63-year-old female patient with a 10-year history of type 2 diabetes; treated on an outpatient basis with metformin 1000 mg/day. We have with HbA1c of the last 3 months: 6.8 %. Enter by exacerbation of COPD, beginning treatment with prednisolone 40 mg VO each 24 hours. On the third day of hospitalization, she presents with persistent hyperglycemia (fasting 160–180 mg/dL, postprandial up to 260 mg/dL). She has not used insulin previously. Her vital signs are stable, with an eGFR of 65 ml/min and an albumin/creatinine ratio of 1000 g/mg.

Perspective:

Glucocorticoids are a common cause of hyperglycemia in the hospital setting. In patients with type 2 diabetes, the use of steroids such as prednisolone power the endurance to the insulin; causing Postprandial and evening hyperglycemia (6). This pathophysiological phenomenon involves adaptations therapeutic specific, mostly based in intermediate-acting insulin (NPH), adjusted to the action profile of the steroid used (6,7,19).

Mechanism :

The prednisolone exercises his effect maximum between 4 and 8 hours after Its administration generates predominantly postprandial and evening hyperglycemia [5, 6]. Its action induces peripheral insulin resistance and increased hepatic gluconeogenesis [5].

Strategy recommended therapy

Patient with stage 2/A3 diabetic kidney disease who, in the presence of significant proteinuria, benefits from initiating treatment with ACE inhibitors/ARBs and statins. and ISLGT2 as measures to promote regression of albuminuria (8,19). At the metabolic level, given that there is no acute infectious process and we have a favorable glomerular filtration rate (greater-than sign 45 ml/min/1.72m 2 ) we can give continuity to management with biguanide [5].

Initiation of insulin therapy: given exacerbation of pulmonary pathology there is a need of management with lows of glucocorticoid (Figure 1) with Subsequent alteration in metabolic homeostasis related to out-of-target blood glucose levels necessitates adjustment of pharmacological therapy until the resolution of the Pulmonary exacerbation and cessation of the described treatment. Prednisolone is an intermediate-acting glucocorticoid that generally affects postprandial blood glucose. In patients without prior use of insulins HE recommends the following options of management [5]:

Option 1 : NPH insulin, dose: 0.3–0.5 IU per each mg of DEP (prednisolone equivalent dose) (0.3 – 0.5 x 40mg). For our patient, the following is calculated with the dose provided of prednisolone, in case of If the patient is already taking another corticosteroid, the equivalent dose of prednisone should be calculated. [5,6]

Example: Prednisolone 40 mg ≈ 12–20 IU of NPH, administer together with the corticosteroid [1,2].

Option 2 : The corticosteroid dose can be adjusted according to a known history of type 2 diabetes or in patients without a history of type 2 diabetes. as indicated in the (Figure 1). Start with 10–20 IU NPH/day and titrate according to blood glucose levels [5,6].

Figure 1, taken from Gianchandani R, Wei M, Demidowich A. Management of Hyperglycemia in Hospitalized Patients. Ann Intern Med. 2024.

Correction with insulin quick (lispro/aspart): in case of persistence In cases of postprandial hyperglycemia, an additional dose of insulin should be added accordingly. to the scheme corrective (Figure 2) in case of GB (blood glucose) basal) greater-than sign 180 mg/dL (5); the intensity should be adapted to individual sensitivity and TDD (total daily dose) [5]. (Figure 2)

In the event that the patient already has a diagnosis of type 2 diabetes mellitus being managed by means of a basal-bolus regimen and presents induced hyperglycemia by glucocorticoid, HE prefers adjust he treatment increasing the preprandial proportion to 60–70% of the DDT, decreasing the amount of basal insulin, however, if there is persistence of hyperglycemia we can increase the preprandial dose by 50%; without modifying the basal dose [5].

Glycemic monitoring: through pre-, postprandial and nightly (10 pm) blood glucose levels; the response will be evaluated every 24–48 hours, according to records HE will be able to adjust the NPH in ±2 UI according to trend [5,6].

Discussion In patients hospitalized with DM2 exposed to steroids, hyperglycemia requires a management insulinic adapted to the guy, dose and glucocorticoid timing. Morning NPH is the agent of choice when ... use steroids intermediate as prednisolone either methylprednisolone in single daily doses [6].

Studies such as those by Stone et al. and Grommesh et al. have shown that NPH-based regimens are effective in controlling steroid-induced hyperglycemia, with a low risk of hypoglycemia if properly adjusted [6].

The ADA and Endocrine Society recommend initiating treatment when blood glucose levels exceed 180 mg/dL on more than two occasions in 24 hours (2, 20), and define goals between 100–140 mg/dl in fast and Less-than sign 180 mg/dl postprandial [7].

A 72-year-old man with a history of recent cerebrovascular disease presented with dysarthria and persistent dysphagia, unable to feed orally. Comorbidities: Type 2 diabetes for 15 years, with an HbA1c of 8.3%. He initiated continuous enteral nutritional support with a standard formula at a rate of 75 ml/hour (1800 kcal/day). He was receiving metformin and glimepiride prior to admission. Blood glucose levels were elevated from the first day greater-than sign 220 mg/dL), with no prior insulin treatment.

Perspective

The prevalence of hyperglycemia in patients with and without diabetes that receive enteral nutrition (NE) is of approximately he 30 % (1). The formulas standard for NE

They have a caloric distribution similar to an oral diet, with 45% to 60?rbohydrates, 20% to 35?ts, and 10% to 20% proteins (1). Specific formulas for diabetes tend to have minor content of carbohydrates and larger quantity of fat and fiber. Although some studies they have demonstrated that They lower fasting glucose levels, but current clinical guidelines do not recommend them over standard formulas [1].

Mechanism pathophysiological

Since patients receiving continuous enteral nutrition are in a constant postprandial state, glucose targets above [value missing] are considered appropriate. of 140 mg/dl for reduce he risk of hypoglycemia [1]. In In these patients, regimens that cover basal, pre-meal, and correction needs achieve superior glycemic control compared to the exclusive use of corrective insulin [1].

Strategy recommended therapy

The use of oral antidiabetic agents is not recommended in hospitalized patients with continuous enteral nutrition, given their potential risk of hypoglycemia, interactions, and unpredictable pharmacokinetics [2]. Sulfonylureas such as glimepiride should be discontinued immediately due to their high hypoglycemic risk. and the metformin has to discontinue by he risk of lactic acidosis in the presence of sepsis or renal dysfunction (2,21,22).

Insulin therapy: Different schemes adaptable to the continuous postprandial state generated by NE (1)

• Insulin NPH each 8 hours : dose of 0.1–0.2 IU/kg each 8 h, can to be preferred when HE wishes a answer of action intermediate and flexible. This scheme may be better adapted if there are frequent changes in the infusion rate or if brief interruptions are anticipated (1).
• Insulin basal (glargine) either degludec) a time to the day + insulin regular every 6 hours : start with 0.2 – 0.3 IU/kg/day. HE recommends that the basal insulin represents less of the 40 % of the dose total daily and dose insulin aspart/lispro every 4 hours adjusted with a correction scale. This is in order to avoid hyperinsulinemia if EN is discontinued (1).
• Rapid-acting insulin (lispro or aspart) every 4 hours : can be used alone or with basal insulin. It is especially useful if rapid adjustment is required or there is a risk of hypoglycemia due to sudden discontinuation of enteral nutrition (1).
• Intravenous insulin infusion : reserved for patients in units reviews either with hyperglycemia persistent to weigh of subcutaneous insulin therapy (1).

Monitoring glycemic: All these regimens should be accompanied by a correction scale and capillary monitoring every 4–6 hours (1,2). If nutrition is interrupted for more than one hour, a dextrose infusion should be started. to the 10 % Yeah the blood glucose is <180>

Discussion: Continuous enteral nutrition (EN) generates a constant glucose stimulus, simulating a sustained postprandial state. This justifies the use of specific regimens. insulins further stable, as he basal-bolus either the Fractionated NPH insulin [5, 15, 16]. The choice depends on the clinical team's experience, the stability of the nutrition, the risk of hypoglycemia, and the possibility of monitoring [5]. NPH insulin has the advantage of allowing more frequent adjustments in patients at risk of discontinuing nutritional support [15]. Basal insulin, such as glargine or degludec, provides greater stability when enteral support is continuous and reliable. In all the cases, is essential count with a scheme correcting and with a strategy preventive in view of suspensions unforeseen aspects of the formula.

A 66-year-old male, hypertensive, dyslipidemic, and with type 2 diabetes mellitus of 12 years' duration, was admitted for ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and placement of a drug-eluting stent. His HbA1c on admission was 7.4%. He was on outpatient treatment with metformin 1000 mg/day and glimepiride 2 mg/day. He had ambulatory continuous glucose monitoring (CGM) with evidence of hypoglycemia. recurring between the 2 and 5 A.M, in time in range (70–180 mg/dL) of 65% and 12% of the time below 70 mg/dL. Renal function was normal (creatinine 1.0 mg/dL, GFR 82 ml/min).

Perspective:

The coexistence of type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (CVD) represents a combination associated with high morbidity and mortality. T2DM triples the risk of cardiovascular events, and these patients present elderly mortality after heart attack sharp myocardial infarction (MI), heart failure, and stroke [3,10]. Glycemic control should be individualized, prioritizing cardiovascular safety, prevention of hypoglycemia, and the selection of antidiabetic agents with proven benefit in major cardiovascular events. (MACE) [1,2,9,10].

Pathophysiological and prognostic considerations:

The hypoglycemia HE associates with arrhythmias ventricular, extension of the QT and sudden death, especially in the context of AMI [3,9,10].

Strategy Recommended therapy :

• The glimepiride has to suspend by his high risk of post-infarction hypoglycemia [3,4].
• Continue metformin if renal function and hemodynamic status allow. [3,9,20].
• Introduction drugs with benefit cardiovascular:
• Empagliflozin 10 mg/day: reduces MACE and hospitalizations for heart failure [1,18]. Consider adding a DPP-4 inhibitor when blood glucose levels are Less-than sign200 mg/dL and the patient has an HbA1c within controlled ranges; however, if hyperglycemia persists during the hospital stay, it is recommended to initiate [the following]. insulin basal temporary (glargine) U100) dose 0.1 IU/kg/day [3, 15, 17].
• Yeah the glucometry persist out of goals HE can do use of a rapid action corrective scheme as shown in the figure 2 [5, 17].
• Regarding GLP- 1: it is an ideal candidate due to its high benefit in he patient with disease atherosclerosis Once established, if initiated, care must be taken to ensure that it is not receiving iDPP4 [3].

Board 1. Scheme corrective of insulin

Table 1, taken from Gianchandani R, Wei M, Demidowich A. Management of Hyperglycemia in Hospitalized Patients. Ann Intern Med. 2024.

Monitoring: This should be performed with pre- and post-meal blood glucose testing for 72 hours post-MI. Continue monitoring during hospital stay. surveillance of parameters metabolic and function renal for prior to discharge, define the best outpatient strategy[3].

The EMPA-REG (1), LEADER (2) and SUSTAIN-6 clinical trials have established that some agents antidiabetic drugs No only control the blood glucose but which also modify he risk cardiovascular, being now first line in patients with type 2 diabetes and established cardiovascular disease. Sulfonylureas, despite their hypoglycemic efficacy, are associated with a higher risk of hypoglycemia and adverse cardiovascular events, especially in elderly patients or those with recent myocardial infarction [4].

The ADA 2025 and ESC/EASD categorically recommend initiating empagliflozin, dapagliflozin, liraglutide either semaglutide in patients GLP- 1 RAs (GLP-1 receptor agonists) are ideal for patients with type 2 diabetes and cardiovascular disease, regardless of baseline glycemic 

control, due to their impact on cardiovascular and renal outcomes [3]. atherosclerosis established and in our case described is feasible in view of his low risk of hypoglycemia. With regard to the The ideal timing for starting the ADA 2024/2025 guidelines allows Consider initiating GLP- 1 RA at two points in time; 1. During hospitalization, especially before discharge; in hemodynamically stable patients without significant nausea neither intolerance oral[ADA 2025, Standards of Care, section 13.6 2.] Immediately after discharge in combination with structured education. There is evidence of reduction of the 14 % of MACE, 13 % of death cardiovascular and 11 % of hospitalization by failure cardiac with benefit additional in weight loss, blood pressure control, and inflammation reduction; all aspects relevant in he patient post heart attack [11,12,13,14].

Figure 2 shows a scheme with the respective titration of hypoglycemic agents according to he level of HbA1c and the comorbidities associated with the diabetic patient in order to best optimize the additional benefits of pharmacotherapy.

Figure 2. Use of hypoglycemic medications in type 2 diabetes. Source: Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025. Diabetes Care , 2025, vol. 48, no Supplement 1, p. S181-S206.

A 70-year-old woman with type 2 diabetes of 18 years' duration, on outpatient treatment with insulin glargine 28 IU/day and glibenclamide 5 mg/day, presents  background of  hypoglycemia  symptomatic nighttime.

Laboratory results: creatinine 2.1 mg/dL, eGFR 22 mL/min/1.73 m², HbA1c: 6.6%. Diagnosis of stage 4 CKD secondary to diabetic kidney disease. No Catabolic symptoms are documented. The patient is hospitalized for a complicated urinary tract infection without criteria for sepsis.

Perspective :

Type 2 diabetes mellitus (T2DM) is the leading cause of chronic kidney disease (ERC) to level world [19, 20]. TO extent that progresses he deterioration of the glomerular filtration rate (GFR), increases the risk of hypoglycemia due to reduced insulin clearance and impaired glucose tolerance. metabolism of medications hypoglycemic agents. The strategy Therapy should prioritize safety, avoid drugs with a high risk of hypoglycemia, and ensure cardiovascular and renal benefits. Individualization is key, especially in frail patients or those in advanced stages of CKD [19, 20].

Managing type 2 diabetes in advanced chronic kidney disease requires a balance between glycemic efficacy and safety [19, 20]. Insulin use should be cautious; starting with reduced doses (0.1–0.2 IU/kg) and slow titrations are recommended [3, 16, 17]. Continued use of sulfonylureas such as glibenclamide in these patients may be problematic. patients increases significantly he risk of hypoglycemia severe and hospitalizations, therefore its use is not recommended in GFR Less-than sign 60 ml/min, especially glibenclamide and glimepiride [21, 22].

Semaglutide, a once-weekly GLP- 1 receptor agonist, has demonstrated both glycemic and renal benefits, with a reduction in major renal events (FLOW trial) and no need for renal function adjustment [23]. Furthermore, it allows for the reduction Progressive safe basal insulin therapy. In patients requiring injectable therapy, initiation of therapy is suggested. with GLP- 1 RA and/or GIP (glucose-dependent insulinotropic polypeptide) before initiating insulin therapy. If HbA1c remains outside target range 3 months after initiating therapy, an adjustment of injectable therapy will be indicated according to the recommendations of the latest ADA 2025 guidelines (Figure 3).

Analysis and Management Plan Considerations clinics relevant:

The glibenclamide has metabolites assets and HE eliminates by via renal by which is contraindicated with GFR Less-than sign 60 ml/min [21].

Exogenous insulin has a prolonged half-life in advanced CKD, with a higher risk of hypoglycemia, especially nocturnal [16, 19].

He patient has a HbA1c in goals without embargo presents episodes of hypoglycemia; it which evidence intensification therapy  of the insulin ,that as HE argued previously increases he risk of mortality .

Interventions proposals:

1.Suspension immediate of glibenclamide.

2.Reduction of dose of insulin of action prolonged in 50 % (of 28 IU → 14 IU/day), with daily reassessment [5].

3.Introduction of agonist of GLP- 1 (semaglutide) SC weekly):

• Sure in TFG ≥15 ml/min, low risk of hypoglycemia [11, 12].
• Demonstrated cardiovascular and renal benefit (FLOW trial) [11,12, 23].

4.Monitoring capillary pre and postprandial, with aim of blood glucose levels in the range 100–180 mg/dL.

5.Avoid metformin, sulfonylureas, and SGLT2i in this stadium of ERC, except for nephroprotective indications under close supervision. (18,20, 21, 22)

Figure 3: Use of hypoglycemic medications in type 2 diabetes. Source: Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025. Diabetes Care , 2025, vol. 48, no Supplement 1, p. S181-S206.

The management of hyperglycemia in hospitalized patients with type 2 diabetes should be individualized, dynamic, and focused on clinical safety. The  presence of  diseases  concomitant and  of  their comorbidities, he state metabolic basal, he reason of hospitalization and the risk of hypoglycemia are determining factors for therapeutic selection . The revision based in cases clinical allows No only translate the evidence in practical decisions, but also to identify common errors in the hospital management of diabetes, such as the omission of corrective scales or the persistence of hypoglycemic agents in changing clinical contexts.

Likewise, the cases also highlight the importance of reconciliation the treatment previous to the exit hospitable, adjusting the therapy of agreement with the clinical status, the function renal and the possibility of adhesion. Of Similarly, it illustrates the need to integrate clinical judgment with the best available evidence Finally, the approach proposed in these cases - based on ADA 2025 guidelines, high-level clinical trials and pathophysiological analysis - contributes to building safe, individualized decision algorithms with real prognostic impact in the hospitalized diabetic population.

None

Statement Of Conflict of Interest

All the researchers we declare No have none conflict of interest

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The present revision No received financing