What is the recommended approach for implementing a sliding scale insulin (SSI) protocol for managing hyperglycemia?

Implementing a Sliding Scale Insulin Protocol for Hyperglycemia Management

Basal-bolus insulin regimens are strongly recommended over traditional sliding scale insulin (SSI) alone for managing hyperglycemia, as SSI by itself leads to poor glycemic control and higher complication rates. 1

Problems with Sliding Scale Insulin Alone

• SSI as a sole therapy is strongly discouraged by the American Diabetes Association due to:
  • Poor glycemic control outcomes 1
  • Higher rates of complications 1
  • Reactive rather than proactive approach to hyperglycemia 2
  • Limited therapeutic success in hospitalized patients 3
  • Persistent hyperglycemia despite treatment 4

Recommended Approach for Insulin Management

For Hospitalized Patients

1. Preferred Regimen: Basal-Bolus Insulin

   • Use basal insulin (long-acting) plus mealtime insulin (short-acting) plus correction insulin 5
   • Total daily dose (TDD): 0.3-0.5 units/kg/day for most patients 1
   • Lower doses (0.2-0.3 units/kg/day) for patients at higher risk of hypoglycemia 1
   • Distribution: 50% as basal insulin, 50% as prandial insulin 1

2. For Patients with Poor Oral Intake or NPO Status

   • Basal plus correction insulin regimen
   • Reduced TDD of 0.1-0.15 units/kg/day, primarily as basal insulin 1

3. For Patients Already on Insulin

   • Reduce home TDD by 20% during hospitalization 1

Insulin Dosing Structure

• Basal insulin: Once or twice daily using long-acting insulin (glargine, detemir, or degludec)
• Prandial insulin: Divided into three doses before meals using rapid-acting insulin (aspart, lispro, or glulisine)
• Correction insulin: Added to prandial doses based on pre-meal glucose levels 5

Recommended Correction Scale

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

Implementation of a Standardized Protocol

To effectively implement a sliding scale insulin protocol as part of a comprehensive insulin regimen:

1. Develop standardized guidelines through an interdisciplinary committee 6
2. Create preprinted physician order forms that include guidelines and standardized insulin scales 6
3. Establish clear target glucose ranges:
   • Premeal targets: <140 mg/dL (7.8 mmol/L)
   • Random blood glucose: <180 mg/dL (10.0 mmol/L) 1
4. Set up a monitoring schedule:
   • Every 4-6 hours when patient is NPO
   • Before meals and at bedtime for patients who are eating 1
5. Implement a hypoglycemia management protocol 1
6. Adjust insulin doses based on patterns of glycemic control:
   • If fasting blood glucose is consistently >140 mg/dL, increase basal insulin dose by 10-20% 1

Avoiding Common Pitfalls

1. Don't use SSI as the sole therapy - This leads to poor outcomes and reactive rather than proactive management 5, 2
2. Don't fail to adjust insulin doses - Studies show that sliding scale regimens are rarely adjusted despite persistent hyperglycemia 4
3. Don't overlook documentation - Ensure proper recording of glucose levels and insulin administration 4
4. Don't miss follow-up monitoring - Regular assessment of glycemic patterns is essential for dose adjustments 1
5. Don't forget to transition appropriately - Have a plan for transitioning from hospital to outpatient regimens 5

Special Considerations

• Perioperative management: Withhold oral agents on the day of surgery; give 60-80% of long-acting insulin dose 1
• Critical illness: Consider IV insulin infusion with target range 140-180 mg/dL 1
• Enteral/parenteral nutrition: Use NPH insulin or glargine/degludec plus regular or rapid-acting insulin 1

By implementing a standardized protocol with basal-bolus insulin rather than relying solely on sliding scale insulin, healthcare facilities can significantly reduce medication errors, decrease episodes of hyperglycemia, and improve overall glycemic control 6.