From the Guidelines
The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, and instead, a basal-bolus insulin regimen or a basal-plus-correction insulin regimen should be used to manage hyperglycemia. This approach is supported by the American Diabetes Association standards of medical care in diabetes, which emphasize the importance of individualizing the insulin regimen based on the patient's specific needs and using a combination of basal and prandial insulin to achieve better glycemic control 1.
When using a sliding insulin scale, it is essential to combine it with basal insulin, rather than using it alone, to avoid poor glycemic control and wide fluctuations in blood glucose levels 1. The sliding scale should be adjusted based on patterns of hyper- or hypoglycemia, taking into account factors such as meal content, physical activity, illness, and medication changes.
Some key points to consider when using a sliding insulin scale include:
- Starting with a well-structured sliding scale that specifies rapid-acting insulin doses corresponding to different blood glucose ranges
- Measuring blood glucose levels before meals and at bedtime
- Adjusting the sliding scale based on patterns of hyper- or hypoglycemia
- Combining the sliding scale with basal insulin to provide background control
- Regularly monitoring and documenting blood glucose levels and insulin doses
The most recent and highest quality study on this topic, published in 2017, supports the use of basal-bolus insulin therapy or basal-plus-correction insulin regimens over sliding-scale insulin alone, citing better glycemic control and fewer treatment failures 1.
Overall, the goal of using a sliding insulin scale is to achieve better glycemic control and reduce the risk of hyperglycemia and hypoglycemia, while also considering the individual patient's needs and adjusting the regimen accordingly.
From the Research
Sliding Insulin Scale Approach
- The use of a sliding insulin scale to manage hyperglycemia is not recommended due to its ineffectiveness and potential dangers 2, 3, 4.
- Instead, a proactive approach to managing diabetes using supplemental insulin, given in conjunction with either considered adjustments to the patient's regular anti-diabetic therapy or the provision of basal insulin, is a more effective and safer means of improving glycemic control in hospital 4.
- Continuous intravenous (IV) insulin infusion is preferred for critically ill patients, while scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed are recommended for non-critically ill patients 3.
Effective Management Strategies
- Basal-bolus plus correction insulin therapy, which involves a single daily dose of insulin glargine at bedtime and bolus injections of rapid-acting insulin shortly before or after meals, is a preferred method for managing hyperglycemia 2.
- The use of long-acting basal insulin analogs (glargine, detemir) and rapid-acting insulin analogs (aspart, lispro, glulisine) can help achieve optimal glycemic control while minimizing the risk of hypoglycemia 3.
- Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels 3.
Specific Patient Populations
- For continuously tube-fed patients, the use of sliding-scale neutral protamine Hagedorn (NPH) insulin has been shown to be a safe and effective management strategy for blood glucose control, resulting in better blood glucose control compared to insulin aspart 5.
- The implementation of a standardized protocol for sliding scale insulin can help decrease medication errors and adverse events related to its use 6.