How do you use sliding scale insulin to manage uncontrolled diabetes?

From the Guidelines

Sliding scale insulin should be used with caution and as part of a comprehensive diabetes management plan, prioritizing basal insulin and adjusting the sliding scale according to individual needs and blood glucose readings, as recommended by the most recent guidelines 1. To use a sliding scale, first check your blood glucose level before meals and at bedtime using a glucose meter. Then, administer the corresponding dose of rapid-acting insulin (such as Humalog, NovoLog, or Apidra) according to your personalized scale. For example, a basic scale might instruct you to take 2 units for blood glucose 150-200 mg/dL, 4 units for 201-250 mg/dL, 6 units for 251-300 mg/dL, and so on.

Key Considerations

• Your healthcare provider will customize this scale based on your individual insulin sensitivity.
• Always administer the insulin subcutaneously in rotating sites (abdomen, thighs, or upper arms) about 15 minutes before meals.
• Keep a log of your readings and insulin doses to share with your provider.
• Sliding scales work because they provide immediate correction for high blood glucose by delivering insulin that helps transport glucose from the bloodstream into cells.
• However, sliding scales are typically used alongside basal insulin (like Lantus or Levemir) for complete diabetes management, as sliding scales alone only address short-term glucose fluctuations rather than providing consistent background insulin coverage.

Adjusting the Sliding Scale

• Consider self-mixed/split insulin plan or twice-daily premixed insulin plan, as suggested by recent guidelines 1.
• Adjust NPH and short/rapid-acting insulins separately, usually unit per unit at the same total insulin dose, but may require adjustment to individual needs.
• Total NPH dose = 80% of current NPH dose, and proceed to full basal-bolus plan (i.e., basal insulin and prandial insulin with each meal) 1.

Important Notes

• Avoid using sliding-scale regular insulin to prevent hypoglycemia and unstable blood glucose, as recommended by recent studies 1.
• Holding insulin due to poor appetite may cause hyperglycemia and diabetic ketoacidosis (DKA), especially in long-term care and hospitals and during care transitions 1.

From the FDA Drug Label

Individualize the dosage of MERILOG based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness

The FDA drug label does not answer the question.

From the Research

Using Sliding Scale Insulin for Uncontrolled Diabetes Management

• Sliding scale insulin is a treatment approach that involves adjusting the dose of insulin based on the patient's blood glucose level, typically used in a hospital setting 2.
• However, there is limited evidence to support the use of sliding scale insulin, and some studies suggest that it may even be detrimental to patient outcomes 2.
• A more effective approach to managing diabetes is to use a proactive strategy, such as supplemental insulin, in conjunction with adjustments to the patient's regular anti-diabetic therapy or basal insulin 2.

Insulin Regimens for Diabetes Management

• For patients with type 1 diabetes, insulin therapy typically involves multiple daily injections of short-acting or rapid-acting insulin, along with one or more daily injections of intermediate or long-acting insulin 3.
• For patients with type 2 diabetes, insulin therapy may involve the use of basal insulin, such as long-acting insulin, or premixed insulin, alone or in combination with oral antidiabetic medications 3.
• The use of rapid-acting or short-acting insulin, such as insulin aspart or insulin lispro, can help to improve postprandial glucose control and reduce the risk of hypoglycemia 4, 5.

Adjusting Insulin Doses

• Blood glucose monitoring is an essential part of effective insulin therapy, and fasting plasma glucose values should be used to titrate basal insulin, while both fasting and postprandial glucose values should be used to titrate mealtime insulin 3.
• The dose of insulin should be adjusted based on the patient's individual needs, taking into account factors such as their diet, physical activity level, and other medications they are taking 3.
• The use of insulin analogs, such as insulin lispro, can provide more flexible dosing options and improve patient outcomes 5, 6.