What is the sliding scale insulin regimen for hyperglycemia?

Understanding Sliding Scale Insulin Regimen 2:50 >150

A sliding scale insulin regimen of "2:50 >150" means administering 2 units of rapid-acting insulin for every 50 mg/dL that the blood glucose exceeds 150 mg/dL. This is a simplified approach to managing hyperglycemia, particularly in hospitalized patients or as a supplemental correction dose alongside a basal insulin regimen.

How Sliding Scale Insulin Works

The sliding scale format follows this structure:

• Starting threshold: 150 mg/dL (the point at which insulin is first administered)
• Increment: 50 mg/dL (the blood glucose range for each dose step)
• Dose: 2 units (the amount of insulin given per increment)

Practical Application

For example:

• Blood glucose 150 mg/dL or below: No insulin given
• Blood glucose 151-200 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
• And so on...

Current Guidelines on Sliding Scale Insulin

According to the American Diabetes Association guidelines, simplified sliding scales can be used as part of insulin management, particularly when adjusting prandial insulin 1. For example:

• Premeal glucose >250 mg/dL (13.9 mmol/L): give 2 units of short- or rapid-acting insulin
• Premeal glucose >350 mg/dL (19.4 mmol/L): give 4 units of short- or rapid-acting insulin

Limitations of Sliding Scale Insulin

Research has shown that when used alone (without basal insulin), sliding scale insulin regimens are associated with a 3-fold higher risk of hyperglycemic episodes compared to no pharmacologic regimen 2. This is because:

• They are reactive rather than preventive
• They don't address basal insulin needs
• They can lead to "roller-coaster" blood glucose patterns

Best Practices for Insulin Management

For optimal glycemic control, current guidelines recommend:

1. Combination approach: Basal insulin plus correction doses (sliding scale) when needed

   • Basal insulin: 0.1-0.2 units/kg/day for elderly patients or 0.3-0.5 units/kg/day for others 3
   • Correction doses: Using a sliding scale format like 2:50 >150

2. Monitoring frequency:

   • For patients on multiple daily insulin injections: Before meals and at bedtime 3
   • For patients on basal insulin only: Daily fasting glucose with pre-meal and bedtime testing 2-3 days per week 3

3. Target glucose ranges:

   • For most hospitalized patients: 140-180 mg/dL 1
   • For non-critically ill patients: Pre-meal <140 mg/dL and random <180 mg/dL 1

Important Considerations

• Discontinuation: Stop sliding scale when not needed daily 1
• Hypoglycemia risk: Higher in patients with African American race and low serum albumin levels 2
• Hyperglycemia risk: Higher in females, patients with severe diabetic complications, high admission glucose levels, infectious disease, and those on corticosteroids 2

Alternative Approaches

For better glycemic control, consider:

• Basal-bolus insulin regimen (basal insulin plus mealtime insulin)
• Basal insulin with non-insulin agents
• Continuous subcutaneous insulin infusion (insulin pump) in appropriate patients

Remember that sliding scale insulin should ideally be used as a temporary measure or as a supplement to a more comprehensive insulin regimen that includes basal coverage, rather than as the sole method of glycemic control.