From the Guidelines
The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, and instead, a basal-plus-correction insulin regimen is recommended for patients with poor oral intake or those who are receiving nothing by mouth 1.
Insulin Regular Sliding Scale Dosage
When considering the use of insulin regular sliding scale dosage for managing hyperglycemia, it's essential to prioritize the most recent and highest quality evidence.
- The most recent evidence from 2023 suggests that the focus should be on titration, increasing the dose by 1–2 units or 10–15% twice weekly, and adjusting for hypoglycemia by determining the cause and lowering the corresponding dose by 10–20% if no clear reason is found 1.
- However, the use of sliding-scale insulin as monotherapy is not recommended due to its ineffectiveness in achieving optimal glycemic control and its potential to cause rapid changes in blood glucose levels, leading to hyper- and hypoglycemia 1.
- A basal-plus-correction insulin regimen is preferred, especially for patients with poor oral intake or those receiving nothing by mouth, as it provides a more balanced approach to glycemic control 1.
Implementation Considerations
For implementation, the insulin regimen should be individualized based on patient factors, including weight, insulin sensitivity, kidney function, and overall health status.
- More insulin-sensitive patients may require a more conservative approach, while insulin-resistant patients may need a more aggressive scale.
- Blood glucose should be checked regularly, and the insulin dose adjusted accordingly to prevent hyper- and hypoglycemia.
Key Recommendations
- Avoid the sole use of sliding-scale insulin in the inpatient hospital setting 1.
- Use a basal-plus-correction insulin regimen for patients with poor oral intake or those receiving nothing by mouth 1.
- Titrate insulin doses based on blood glucose levels, increasing the dose by 1–2 units or 10–15% twice weekly, and adjusting for hypoglycemia as needed 1.
From the Research
Insulin Regular Sliding Scale Dosage
The recommended insulin regular (IR) sliding scale dosage for managing hyperglycemia is not supported by recent studies.
- According to 2, sliding-scale insulin is not recommended because it is ineffective and potentially dangerous.
- A meta-analysis of randomized controlled trials found that sliding-scale insulin did not provide any benefits in blood glucose control, but was accompanied by an increased incidence of hyperglycemic events 3.
- Another study found that nurse-managed blood glucose control in critical care was as safe and effective as the traditional sliding scale method, and that an insulin infusion protocol that uses the last two blood glucose levels to determine the new infusion rate was better at maintaining glycemic control than the traditional sliding scale method 4.
- The use of sliding-scale insulin is not supported by recent clinical practice guidelines, which recommend the use of basal-bolus insulin therapy or continuous intravenous insulin infusions instead 2, 5.
Alternative Treatment Options
Alternative treatment options for managing hyperglycemia include:
- Basal-bolus insulin therapy, which involves a single daily dose of insulin glargine at bedtime to prevent gluconeogenesis and ketogenesis, bolus injections of a rapid-acting insulin shortly before or after meals to meet prandial requirements, and correction bolus injections of rapid-acting insulin as needed for blood glucose elevations before or between meals 2.
- Continuous intravenous insulin infusions, which can help to achieve and maintain glycemic control in hospitalized patients 2, 5.
- Metformin, an oral biguanide that ameliorates hyperglycemia by improving peripheral sensitivity to insulin, and reducing gastrointestinal glucose absorption and hepatic glucose production 6.