What is a sliding scale insulin (SSI) regimen?

From the Guidelines

Sliding scale insulin regimens are generally not recommended as monotherapy due to their reactive nature and potential to cause rapid changes in blood glucose levels, leading to hyper- and hypoglycemia 1. When considering the use of sliding scale insulin, it is essential to prioritize the patient's individual needs and health status. The most recent guidelines suggest that sliding scale insulin regimens may be used in specific situations, such as in hospitalized patients or during illness, but should be used with caution and as part of a comprehensive treatment plan 1. Some key points to consider when using a sliding scale insulin regimen include:

• Checking blood glucose levels before meals and at bedtime to determine the appropriate insulin dose
• Using a simplified sliding scale, such as giving 2 units of short- or rapid-acting insulin for premeal glucose >250 mg/dL (>13.9 mmol/L) and 4 units for premeal glucose >350 mg/dL (19.4 mmol/L) 1
• Stopping the sliding scale when not needed daily
• Adjusting insulin doses and adding glucose-lowering agents as needed, based on fingerstick glucose testing performed before lunch and before dinner
• Setting a goal of 90–150 mg/dL (5.0–8.3 mmol/L) before meals, with adjustments made based on overall health and goals of care 1 It is crucial to note that sliding scale insulin regimens should be personalized to the individual patient's needs and health status, and should be used in conjunction with other treatment strategies to achieve optimal blood glucose control. The use of basal-bolus insulin therapy, which includes both long-acting and short-acting insulin, is generally preferred over sliding scale insulin regimens due to its ability to provide more consistent and controlled blood glucose levels 1.

From the Research

Sliding Scale Insulin

• Sliding scale insulin is a treatment regimen for managing high blood sugar levels, particularly in patients with diabetes 2.
• The regimen involves adjusting the dose of insulin based on the patient's blood glucose level, with the goal of maintaining blood sugar levels within a target range.

Types of Insulin

• Rapid-acting insulin analogues, such as insulin aspart and insulin lispro, have been developed to more closely replicate the physiology of meal-related insulin secretion 2, 3.
• Basal insulin analogues, such as insulin glargine and insulin detemir, have been developed to provide a more stable and prolonged basal insulin supply 2, 4.
• Premixed insulin analogues, such as biphasic insulin aspart, have been developed to address both prandial and basal insulin needs with a single product 5.

Efficacy of Insulin Analogues

• Rapid-acting insulin analogues have been shown to reduce postprandial glucose excursions and hypoglycemia compared to human insulin 2, 3, 4.
• Basal insulin analogues have been shown to reduce hypoglycemia, particularly nocturnal hypoglycemia, and may also reduce weight gain compared to human basal insulin 2, 4.
• Premixed insulin analogues have been shown to control postprandial glucose better than human insulin mixes and may have advantages in basal-bolus therapy 5, 4.

Comparison of Insulin Analogues

• Insulin aspart and insulin lispro have been shown to be equivalent in terms of pharmacodynamic and pharmacokinetic profiles 3.
• Insulin glulisine has been shown to have comparable glucose control to lispro and aspart, although it may have a higher rate of lipodystrophy and non-severe diabetic ketoacidosis 6.
• Biphasic insulin aspart has been shown to provide improved postprandial glucose control compared to biphasic human insulin and NPH insulin 5.