What are the guidelines for sliding scale insulin (SSI) management in inpatient settings with impaired glucose regulation?

Guidelines for Sliding Scale Insulin Management in Inpatient Settings

Sliding scale insulin (SSI) alone is strongly discouraged for inpatient management of hyperglycemia and should be replaced with basal-bolus insulin regimens to improve glycemic control and patient outcomes. 1, 2

Recommended Insulin Regimens for Inpatients

Preferred Approach: Basal-Bolus Insulin

• Basal insulin (glargine, detemir, or degludec) once daily plus prandial insulin (lispro, aspart, or glulisine) before meals is the recommended regimen for hospitalized patients with diabetes or hyperglycemia 1, 2
• For patients with good nutritional intake, use a complete basal-bolus-correction regimen 1, 2
• For patients with poor oral intake or NPO status, use a basal plus correction insulin regimen 1
• Starting dose recommendations: 0.5 U/kg/day total insulin with approximately 50% as basal insulin and 50% as prandial insulin divided before meals 2, 3
• Dose adjustments should be made based on individual patient factors (renal/hepatic function, age, weight) 3

Blood Glucose Targets

• For most hospitalized non-critically ill patients, target premeal blood glucose <140 mg/dL (7.8 mmol/L) and random blood glucose <180 mg/dL (10.0 mmol/L) 1
• More stringent targets may be appropriate for stable patients with previous tight glycemic control, while less stringent targets may be suitable for patients with severe comorbidities 1

Why SSI Alone Should Be Avoided

• SSI alone has been shown to be ineffective as monotherapy in patients with established insulin requirements 1, 4
• SSI treats hyperglycemia reactively after it occurs rather than preventing hyperglycemia 1, 2
• SSI regimens are often used throughout hospitalization without modification despite poor control 1
• Meta-analysis shows SSI alone does not provide benefits in blood glucose control and is associated with increased incidence of hyperglycemic events 4

Special Situations

Continuous Enteral Nutrition

• For patients on continuous tube feedings, consider NPH insulin every 6-8 hours rather than sliding scale rapid-acting insulin 5
• Total daily insulin dose should be similar to that used for patients on regular meals (0.6-1.0 U/kg/day) 3
• NPH insulin has been shown to provide better glycemic control than rapid-acting insulin in continuously tube-fed patients 5

Nil Per Os (NPO) Patients

• For NPO patients, use basal insulin with correction doses 1
• Consider reducing basal insulin dose by 20-30% when patients are not receiving nutritional intake 2
• Monitor blood glucose every 4-6 hours and adjust insulin accordingly 2, 6

Preventing Hypoglycemia

• Implement a hypoglycemia management protocol for each patient 1, 2
• Document episodes of hypoglycemia in the medical record and track patterns 1
• Reassess insulin regimen if blood glucose levels fall below 100 mg/dL (5.6 mmol/L) 1
• Modify regimen when blood glucose values are <70 mg/dL (3.9 mmol/L) unless easily explained by other factors 1
• Be aware that the risk of hypoglycemia with basal-bolus insulin is about 4-6 times higher than with SSI therapy 1

Implementation Recommendations

• Transition from SSI to basal-bolus insulin as soon as possible after admission 2
• Perform glucose monitoring before meals and at bedtime for patients who are eating, or every 4-6 hours for patients who are NPO 2, 6
• Adjust insulin doses daily based on patterns of glycemic control 1, 2
• Use rapid-acting insulin analogs (aspart, lispro, glulisine) for correction doses rather than regular insulin due to their more predictable action profile 7, 3
• Never share insulin pens between patients to prevent transmission of blood-borne pathogens 7

Common Pitfalls to Avoid

• Using premixed insulin formulations in the hospital setting, which has been associated with unacceptably high rates of hypoglycemia 1, 2
• Continuing SSI throughout hospitalization without reassessment or modification 1, 2
• Withholding basal insulin when blood glucose is elevated, which can lead to worsening hyperglycemia 2
• Failing to monitor blood glucose after insulin administration, increasing the risk of undetected hypoglycemia 2
• Delaying transition from intravenous to subcutaneous insulin in critically ill patients who are stabilizing 8

By implementing these evidence-based guidelines for inpatient insulin management, healthcare providers can improve glycemic control, reduce complications, and enhance patient outcomes during hospitalization.