From the Guidelines
The use of sliding scale insulin (SSI) as monotherapy for hyperglycemia management is strongly discouraged, and instead, a basal-bolus approach with basal and prandial insulin is recommended for optimal glycemic control. This approach is supported by the most recent and highest quality study, which emphasizes the importance of addressing both basal and prandial insulin needs to achieve optimal glycemic control 1.
Key Considerations for Sliding Scale Insulin
- Sliding scale insulin should only be used as a supplemental therapy alongside basal insulin, except in specific short-term situations.
- The scale should be individualized based on patient sensitivity to insulin, with lower doses for insulin-sensitive patients and higher doses for insulin-resistant patients.
- Blood glucose should be monitored regularly to assess effectiveness, and the scale should be adjusted if glucose targets aren't being met.
Preferred Approach
- A basal-bolus approach, which includes basal insulin and rapid-acting insulin before meals, plus corrective doses of rapid-acting insulin, is recommended for optimal glycemic control.
- For insulin-naive patients or those treated with low doses of insulin, a total daily insulin dose between 0.3 and 0.5 U/kg is recommended, with half allocated to basal insulin and the other half to rapid-acting insulin 1.
Important Notes
- The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged due to its association with clinically significant hyperglycemia and lack of addressing basal insulin needs 1.
- A basal-plus approach, which consists of a single dose of basal insulin along with corrective doses of insulin, might be preferred for patients with mild hyperglycemia or those with decreased oral intake 1.
From the Research
Protocol for Using Sliding Scale Insulin (SSI)
The proper protocol for using SSI in patients with hyperglycemia involves several key considerations:
- SSI is typically used in a hospital setting to manage hyperglycemia in non-critically ill patients 2, 3.
- The regimen involves administering insulin based on the patient's blood glucose level, with the goal of achieving target glucose levels 2, 3.
- However, studies have shown that SSI may not be the most effective strategy for achieving glycemic control, and may be associated with an increased risk of hyperglycemic events 2, 3.
- Alternative strategies, such as basal-bolus insulin, may be more effective in achieving glycemic control and reducing the risk of hypoglycemia 4, 3, 5.
Key Considerations for SSI Use
Some key considerations for using SSI include:
- Monitoring blood glucose levels regularly to adjust insulin doses 2, 3.
- Using a standardized protocol for administering SSI to minimize errors and ensure consistency 2, 3.
- Considering alternative strategies, such as basal-bolus insulin, for patients who are not achieving adequate glycemic control with SSI 4, 3, 5.
- Being aware of the potential risks and benefits of SSI, including the risk of hyperglycemic events and hypoglycemia 2, 3.
Comparison with Other Insulin Regimens
Studies have compared SSI with other insulin regimens, including basal-bolus insulin:
- A meta-analysis found that SSI was not superior to other regimens in achieving glycemic control, and may be associated with an increased risk of hyperglycemic events 2.
- A systematic review found that basal-bolus insulin may be more effective in achieving glycemic control and reducing the risk of hypoglycemia 3.
- A retrospective study found that patients treated with basal-bolus insulin achieved better glycemic control than those treated with SSI 5.