How to transition a patient to inpatient sliding scale insulin when they are on home metformin (Metformin) and Jardiance (Empagliflozin)?

From the Guidelines

When transitioning a patient from home metformin and Jardiance to an inpatient regimen, I recommend initiating a basal-bolus insulin regimen with correction doses, rather than a sliding scale insulin regimen, as it provides better glycemic control and reduces the risk of hypoglycemia and other complications, as supported by the most recent and highest quality study 1.

Key Considerations

• Discontinue Jardiance immediately upon admission due to the risk of euglycemic diabetic ketoacidosis during acute illness.
• Discontinue metformin if the patient has acute kidney injury, is NPO, or undergoing procedures with contrast.
• Start with a weight-based basal insulin (such as insulin glargine 0.2-0.3 units/kg/day) plus mealtime rapid-acting insulin (such as insulin lispro or aspart 0.05-0.1 units/kg/meal).
• Add correction doses of rapid-acting insulin every 4-6 hours based on blood glucose readings, typically starting with 1 unit for every 50 mg/dL above 150 mg/dL.
• Monitor blood glucose before meals and at bedtime, adjusting the insulin doses daily.

Rationale

The use of a basal-bolus insulin regimen with correction doses is supported by recent guidelines, including the 2022 Diabetes Care study 1, which recommends this approach for non-critically ill patients with diabetes. This regimen provides better glycemic control and reduces the risk of hypoglycemia and other complications compared to sliding scale insulin regimens.

Additional Tips

• Avoid using rapid- and short-acting insulin at bedtime, as recommended by the 2022 Diabetes Care study 1.
• Consider using a simplified sliding scale for adjusting prandial insulin, as depicted in the 2022 Diabetes Care study 1.
• Stop sliding scale when not needed daily, and adjust insulin dose and/or add glucose-lowering agents based on fingerstick glucose testing performed before lunch and before dinner, with a goal of 90-150 mg/dL before meals.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Transitioning to Inpatient Sliding Scale

To transition a patient to an inpatient sliding scale when they are on home metformin and Jardiance, consider the following steps:

• Review the patient's current medication regimen, including metformin and Jardiance, and assess their glucose control 2, 3, 4, 5, 6.
• Evaluate the patient's insulin needs and consider adding a basal insulin or adjusting their current insulin regimen 2, 3, 4, 5, 6.
• Consider the use of a premixed insulin, such as biphasic insulin aspart, which can provide both basal and prandial insulin coverage 4, 5, 6.
• Monitor the patient's glucose levels closely and adjust their insulin regimen as needed to achieve optimal glucose control 2, 3, 4, 5, 6.
• Consider the patient's individual needs and preferences when selecting an insulin regimen, and involve them in the decision-making process whenever possible.

Key Considerations

• The patient's current medication regimen, including metformin and Jardiance, should be continued unless otherwise indicated 2, 3, 4, 5, 6.
• The patient's insulin needs should be evaluated and adjusted as needed to achieve optimal glucose control 2, 3, 4, 5, 6.
• The use of a premixed insulin, such as biphasic insulin aspart, can provide both basal and prandial insulin coverage and may be a convenient option for some patients 4, 5, 6.
• Close monitoring of the patient's glucose levels is necessary to adjust their insulin regimen as needed and achieve optimal glucose control 2, 3, 4, 5, 6.

Insulin Regimens

• Basal insulin, such as insulin glargine, can provide 24-hour glucose coverage and is often used in combination with oral medications, such as metformin and Jardiance 2, 3, 6.
• Premixed insulin, such as biphasic insulin aspart, can provide both basal and prandial insulin coverage and may be a convenient option for some patients 4, 5, 6.
• The choice of insulin regimen should be individualized based on the patient's needs and preferences, and should take into account their lifestyle, glucose control goals, and other health factors 2, 3, 4, 5, 6.