What is the protocol for a sliding scale of insulin (Regular Insulin) therapy?

From the Guidelines

The use of a sliding scale of insulin as the sole regimen is strongly discouraged in favor of a basal-bolus approach for better glycemic control and reduced risk of complications, as recommended by the most recent and highest quality study 1.

Key Points to Consider

• The sliding scale insulin regimen is associated with undesirable hypoglycemia and hyperglycemia, and increased risk of hospital complications 1.
• A basal-bolus approach, which includes basal insulin and prandial insulin, is the preferred treatment for patients with good nutritional intake 1.
• For patients with poor oral intake or those receiving nothing by mouth, a basal-plus-correction insulin regimen is recommended 1.
• The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged due to its association with clinically significant hyperglycemia and increased risk of complications 1.

Implementation of Basal-Bolus Regimen

• The total daily insulin dose should be between 0.3 and 0.5 U/kg, with half allocated to basal insulin and the other half to rapid-acting insulin 1.
• The basal insulin dose should be given once or twice daily, and the rapid-acting insulin dose should be given before meals, with corrective doses as needed 1.
• The insulin regimen should be personalized based on the patient's nutritional status, body weight, and hypoglycemia risk 1.

Monitoring and Adjustments

• Point-of-care glucose testing should be performed immediately before meals to adjust the prandial insulin dose based on carbohydrate intake and pre-meal glucose levels 1.
• The insulin regimen should be adjusted as needed to achieve glycemic targets and prevent hypoglycemia 1.

From the Research

Protocol for Sliding Scale of Insulin Therapy

The protocol for a sliding scale of insulin (Regular Insulin) therapy is not directly addressed in the provided studies. However, some studies discuss the use of sliding-scale insulin (SSI) regimens:

• According to 2, SSI regimens are not effective and should not be used, especially as this excludes a basal insulin component from the therapy.
• Instead, scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring are recommended for non-critically ill inpatients.

Alternative Insulin Therapies

Some studies discuss alternative insulin therapies, including:

• Basal-bolus insulin regimens, which mimic normal release patterns and are recommended for replacement therapy 3
• Augmentation therapy with basal insulin, which is useful if some beta-cell function remains 3
• Rapid-acting insulin analogs (aspart, lispro, glulisine) for bolus and correction doses 2
• Long-acting basal insulin analogs (glargine, detemir) for the basal component of therapy 2

Key Considerations

Key considerations for insulin therapy include:

• Prevention of hypoglycemia, which is equally as important to patient outcomes as glycemic control 2
• Frequent and effective glucose monitoring to avoid wide deviations from acceptable glucose levels 2
• Adjustment of insulin doses systematically, starting with the fasting, then the preprandial and, finally, the postprandial glucose levels 3