From the Guidelines
The most effective protocol for short-acting (Regular) insulin sliding scale is to use a simplified scale, such as: premeal glucose >250 mg/dL, give 2 units of short- or rapid-acting insulin, and premeal glucose >350 mg/dL, give 4 units of short- or rapid-acting insulin, as recommended by the most recent study 1. This approach is supported by the latest evidence, which suggests that sliding-scale insulin regimens should be used with caution and ideally combined with basal insulin for better glycemic control 1. When implementing a short-acting insulin sliding scale, it is essential to:
- Use rapid-acting insulins like Humalog (insulin lispro), NovoLog (insulin aspart), or Apidra (insulin glulisine)
- Check blood glucose before meals and at bedtime, administering insulin according to the scale
- Document each reading and insulin dose given
- Individualize the scale based on patient sensitivity to insulin, weight, and other factors
- Regularly reassess and adjust the scale based on glucose patterns and patient response, as recommended by recent studies 1. It is also important to note that sliding scales should be stopped when not needed daily and that noninsulin agents can be added to simplify complex insulin therapy, as suggested by recent guidelines 1.
From the Research
Protocol for Short-Acting (Regular) Insulin Sliding Scale
- The protocol for short-acting (regular) insulin sliding scale is not recommended as it is ineffective and potentially dangerous 2
- Instead, continuous intravenous (i.v.) insulin therapy or intermittent subcutaneous (s.c.) basal-bolus plus correction injections is preferred 2
- Basal-bolus plus correction insulin therapy usually 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
- Some studies have shown that carbohydrate counting sliding scale can be effective in reducing blood glucose levels in hospitalized diabetic patients 3
- However, other studies have found that sliding-scale insulin regimens are often ineffectual and prone to deficiencies in monitoring, documentation, and prescribing soundness 4
Key Considerations
- Target blood glucose concentrations depend on whether patients are critically ill or not 2
- Factors that can complicate glycemic control include the severity of illness, medications, and inconsistent dietary intake 2
- The expected course of treatment, anticipated length of stay, and preadmission glycemic control influence the aggressiveness of therapy to manage hyperglycemia 2
- Hypoglycemia is the primary limiting factor for achieving optimal glycemic control with insulin therapy 2