Standard Sliding Scale Insulin Regimen for Hyperglycemia Management
The sole use of sliding scale insulin (SSI) in the inpatient hospital setting is strongly discouraged and should not be used as the primary method for managing hyperglycemia. 1
Preferred Insulin Regimens Over SSI
A basal-bolus insulin regimen is the preferred treatment approach for managing hyperglycemia in hospitalized patients, rather than sliding scale insulin alone. This approach includes:
For patients with good nutritional intake:
- Basal insulin (long-acting): 50% of total daily dose
- Prandial insulin (rapid-acting): 50% of total daily dose divided before meals
- Correction insulin as needed 1
For patients with poor oral intake or NPO status:
When Sliding Scale Insulin Might Be Appropriate
While generally discouraged, sliding scale insulin alone may be appropriate in limited circumstances:
- Patients without diabetes who have mild stress hyperglycemia 1
- Patients with HbA1c <7% or normal blood glucose on dietary management or low-dose oral agents 1
- Patients with mild hyperglycemia who are NPO with no nutritional replacement 1
Reasons to Avoid Sliding Scale Insulin Alone
- Associated with clinically significant hyperglycemia 1
- Higher mean blood glucose levels compared to basal-bolus regimens 2
- Increased incidence of hyperglycemic events 2
- Does not provide basal insulin coverage 3
- Reactive rather than proactive approach to glucose management
Blood Glucose Targets
- Target blood glucose range: 140-180 mg/dL (7.8-10.0 mmol/L) for most hospitalized patients 1
- More stringent targets (110-140 mg/dL) may be appropriate for selected patients if achievable without significant hypoglycemia 1
Example of Standardized Correction Insulin Scale
When correction insulin is needed as part of a basal-bolus regimen, a standardized approach with different intensity levels based on insulin sensitivity is recommended:
| Blood Glucose (mg/dL) | Low-Dose Scale | Moderate-Dose Scale | High-Dose Scale |
|---|---|---|---|
| 140-180 | 1 unit | 2 units | 3 units |
| 181-220 | 2 units | 4 units | 6 units |
| 221-260 | 3 units | 6 units | 9 units |
| 261-300 | 4 units | 8 units | 12 units |
| >300 | 5 units | 10 units | 15 units |
Monitoring and Adjustment
- Check blood glucose before meals and at bedtime for patients who are eating 4
- Check every 4-6 hours for NPO patients 4
- Adjust insulin doses based on patterns of glycemic control 4
- Implement a hypoglycemia management protocol to prevent and treat low blood glucose 1
Important Cautions
- Never use sliding scale insulin alone in patients with type 1 diabetes 1
- Avoid premixed insulin therapy in the hospital due to high risk of hypoglycemia 1
- Reduce total daily insulin dose by approximately 20% for patients on higher doses at home (≥0.6 units/kg/day) to prevent hypoglycemia during hospitalization 1
By following these evidence-based recommendations, hyperglycemia can be managed more effectively while reducing the risks associated with outdated sliding scale insulin regimens.