What is the typical regimen for sliding scale insulin (SSI) orders?

Sliding Scale Insulin Regimen Guidelines

The typical regimen for sliding scale insulin (SSI) should include a basal insulin component plus correctional doses of rapid-acting insulin, as SSI alone is ineffective and strongly discouraged in clinical guidelines. 1

Recommended Approach to Sliding Scale Insulin

• Sliding scale insulin should not be used as monotherapy but rather as part of a comprehensive insulin regimen that includes basal insulin 2, 1
• For patients with adequate oral intake, a basal-bolus regimen is recommended with total daily dose (TDD) of 0.3 units/kg, divided as half basal and half prandial insulin 2
• For patients with poor oral intake, use a lower total daily dose (0.1-0.25 units/kg) of basal insulin plus correction doses of rapid-acting insulin 2, 1

Example of a Simplified Sliding Scale Component

• For premeal glucose >250 mg/dL (>13.9 mmol/L): give 2 units of short- or rapid-acting insulin 2
• For premeal glucose >350 mg/dL (>19.4 mmol/L): give 4 units of short- or rapid-acting insulin 2
• Lower doses should be used for patients at higher risk of hypoglycemia (elderly, renal failure, poor oral intake) 1

Patient-Specific Considerations

• For insulin-naïve patients: Start with lower doses (0.3 units/kg/day total) 2
• For patients on higher insulin doses at home (≥0.6 units/kg/day): Reduce total daily dose by 20% during hospitalization to prevent hypoglycemia 1
• For critically ill patients: Continuous intravenous insulin infusion is preferred with target glucose range of 140-180 mg/dL 2, 1

Adjusting the Regimen

• If 50% of premeal finger-stick values over 2 weeks are above goal (90-150 mg/dL), increase the dose or add another agent 2
• If >2 premeal finger-stick values/week are <90 mg/dL, decrease the medication dose 2
• When transitioning from IV insulin to subcutaneous insulin, use 80% of the total daily IV insulin requirement as the starting subcutaneous dose 3

Common Pitfalls to Avoid

• Using sliding scale insulin alone is ineffective and leads to poor glycemic control with wide glucose fluctuations 2, 4
• Continuing the same sliding scale regimen throughout hospitalization without modification despite poor control 1
• Using premixed insulin formulations (70/30) in the hospital setting, which has been associated with higher rates of hypoglycemia compared to basal-bolus regimens 2
• Using rapid-acting or short-acting insulin at bedtime, which increases hypoglycemia risk 2

Evidence Supporting Recommendations

• Randomized trials show better glycemic control with basal-bolus approach than with sliding scale insulin alone, with target glucose control achieved in 68% of patients on basal-bolus versus only 38% with sliding scale insulin alone 1
• Traditional sliding scale regimens without intermediate or long-acting insulins have been shown to be ineffective when used as monotherapy in patients with established insulin requirements 2
• The reactive approach of sliding scale insulin leads to rapid changes in blood glucose levels, exacerbating both hyper- and hypoglycemia 2, 4