What is the protocol for a sliding scale insulin (SSI) regimen?

Sliding Scale Insulin Regimen Protocol

The standard sliding scale insulin (SSI) regimen should not be used as monotherapy for hospitalized patients with diabetes, as it is ineffective when used alone and should be combined with scheduled basal insulin for optimal glycemic control. 1

Proper Insulin Management Approach

Basal-Bolus Insulin Regimen (Preferred Approach)

• Basal insulin component:

  • Start with 0.1-0.25 units/kg/day of long-acting insulin (glargine, detemir, or degludec) 2, 3
  • Administer once daily, typically in the morning or evening 3
  • Titrate dose based on fasting glucose values:
    • If 50% of fasting glucose values are above target: Increase by 2 units 1
    • If >2 fasting glucose values/week are <80 mg/dL: Decrease by 2 units 1

• Bolus (prandial) insulin component:

  • Use rapid-acting insulin (lispro, aspart, glulisine) or short-acting (regular) insulin before meals 1
  • Starting dose: Calculate as 50% of total daily insulin requirement, divided among meals 1

• Correction (supplemental) insulin component:

  • Add to scheduled prandial doses to correct pre-meal hyperglycemia
  • Example of correction scale for average insulin sensitivity 1:
    • Blood glucose 150-200 mg/dL: 2 units
    • Blood glucose 201-250 mg/dL: 4 units
    • Blood glucose 251-300 mg/dL: 6 units
    • Blood glucose 301-350 mg/dL: 8 units
    • Blood glucose 351-400 mg/dL: 10 units
    • Blood glucose >400 mg/dL: 12 units and notify physician

Blood Glucose Monitoring

• Check blood glucose before meals and at bedtime for patients who are eating 1
• For NPO patients, check every 4-6 hours 1
• Target blood glucose range: 140-180 mg/dL for most hospitalized patients 1

Special Considerations

Type 1 Diabetes

• Always maintain basal insulin even when NPO to prevent ketoacidosis 1
• Basal insulin dosing should be based on body weight, with adjustments for renal insufficiency 1
• An insulin regimen with basal and correction components is necessary for all hospitalized patients with type 1 diabetes 1

Transitioning from IV to Subcutaneous Insulin

• Start subcutaneous basal insulin 2-4 hours before discontinuing IV insulin 1
• Convert to basal insulin at 60-80% of the daily IV infusion dose 1

Hypoglycemia Prevention

• Implement a hypoglycemia management protocol 1
• Document all episodes of hypoglycemia in the medical record 1
• Predictors of hypoglycemia: prior episodes of hypoglycemia during the same admission, use of basal insulin (particularly between midnight and 6 AM) 1

Why Sliding Scale Insulin Alone Is Problematic

1. SSI treats hyperglycemia reactively rather than preventively 1, 4
2. Studies show SSI alone results in poorer glycemic control compared to basal-bolus regimens 5
3. SSI is associated with more frequent hyperglycemic episodes 6, 4
4. The RABBIT 2 trial demonstrated that basal-bolus regimens achieved target glucose in 66% of patients versus only 38% with SSI alone 5

Implementation Tips

• Use standardized order forms to reduce medication errors 6
• Adjust insulin doses every 1-2 days based on glucose patterns 1
• For patients transitioning from hospital to home, simplify regimens when possible 1, 2
• Do not use rapid-acting or short-acting insulin at bedtime due to hypoglycemia risk 1
• Stop sliding scale when no longer needed daily 1

Common Pitfalls to Avoid

1. Continuing SSI throughout hospitalization without modification despite poor control 4
2. Failing to document glucose measurements and insulin administration accurately 4
3. Not adjusting insulin doses despite persistently elevated glucose levels 4
4. Using premixed insulin formulations in the inpatient setting (associated with increased hypoglycemia) 1
5. Omitting basal insulin in patients with type 1 diabetes, even when NPO 1

By implementing a structured basal-bolus insulin regimen with appropriate correction doses rather than relying solely on sliding scale insulin, you can achieve better glycemic control and reduce both hyperglycemic and hypoglycemic events in hospitalized patients.