Diabetes Sliding Scale Insulin Regimen
The preferred insulin regimen for diabetes management is a basal-bolus approach rather than traditional sliding scale insulin (SSI) alone, as SSI by itself is ineffective and may lead to poor glycemic control with increased hyperglycemic events. 1
Recommended Insulin Regimen Structure
Basal-Bolus Insulin Approach
- Total Daily Dose (TDD): 0.3-0.5 units/kg/day for most patients 1
- Lower starting doses (0.2-0.3 units/kg/day) for elderly patients, those with renal failure, or poor oral intake
- Distribution:
- 50% as basal insulin (long-acting)
- 50% as prandial insulin (rapid-acting) divided into three doses before meals 1
Supplemental Correction Insulin
When using correction insulin as part of a comprehensive regimen, the following scale 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 |
| 301-350 | 5 units | 10 units | 15 units |
| 351-400 | 6 units | 12 units | 18 units |
Choose scale based on insulin sensitivity: Low-dose for insulin-sensitive patients, moderate-dose for average patients, high-dose for insulin-resistant patients 1
Special Situations
For Patients with Poor Oral Intake or NPO Status
- Use basal plus correction insulin regimen
- Reduce TDD to 0.1-0.15 units/kg/day, primarily as basal insulin 1
- Monitor blood glucose every 4-6 hours 2
For Patients on Enteral/Parenteral Nutrition
- Continue prior basal insulin or start with 5 units NPH/detemir every 12 hours or 10 units glargine/degludec daily
- Add nutritional insulin: 1 unit per 10-15g carbohydrate 2
- For continuous enteral feedings: Regular insulin every 6 hours or rapid-acting insulin every 4 hours
- For bolus enteral feedings: Regular or rapid-acting insulin before each feeding
Monitoring and Adjustment
- Monitor blood glucose before meals and at bedtime for patients who are eating
- Target blood glucose range: 90-150 mg/dL (5.0-8.3 mmol/L) before meals 2
- If 50% of fasting finger-stick values are over goal: Increase basal dose by 2 units
- If >2 fasting finger-stick values/week are <80 mg/dL: Decrease basal dose by 2 units 2
Why Traditional Sliding Scale Alone Is Problematic
Traditional sliding scale insulin (SSI) regimens have significant limitations:
- Treats hyperglycemia reactively after it occurs rather than preventing it 2
- Often used without modification throughout hospital stay despite poor control 2
- Associated with higher rates of hyperglycemic events 3
- Lacks evidence for clinical benefit and may be detrimental 4
A meta-analysis of randomized controlled trials showed that sliding scale insulin alone did not provide benefits in blood glucose control and was associated with increased hyperglycemia 3.
Implementation Tips
- Use standardized order forms to reduce medication errors 5
- Document blood glucose levels and insulin administration carefully
- Adjust insulin doses based on patterns of glycemic control, not just individual readings
- Have a hypoglycemia management protocol in place 2
Common Pitfalls to Avoid
- Using sliding scale insulin as the sole therapy 2, 1
- Failing to adjust insulin doses based on patterns of glycemic control
- Missing documentation of blood glucose levels or insulin administration
- Not having a plan for transitioning from hospital to outpatient regimens
By implementing a structured basal-bolus insulin regimen with appropriate correction doses, healthcare providers can achieve better glycemic control and reduce complications compared to traditional sliding scale insulin alone.