What type of insulin is used for sliding scale insulin therapy?

Insulin Type for Sliding Scale Therapy

Traditional sliding scale insulin regimens use regular insulin, though this approach is strongly discouraged as monotherapy and should be replaced with basal-bolus insulin regimens that provide superior glycemic control and reduce complications. 1

What Insulin is Traditionally Used

• Regular insulin is the insulin type historically used in traditional sliding scale regimens 1
• There are no studies comparing human regular insulin with rapid-acting analogs (such as insulin aspart or lispro) for use as correction-dose insulin 1
• Both regular insulin and rapid-acting analogs can be used for correction doses, though the evidence base does not favor one over the other 1

Critical Limitation: Sliding Scale Insulin Alone is Ineffective

The American Diabetes Association strongly discourages the sole use of sliding scale insulin in hospitalized patients 1, as this approach:

• Treats hyperglycemia reactively after it has already occurred rather than preventing it 1
• Results in poor glycemic control, with only 38% of patients achieving mean blood glucose <140 mg/dL compared to 68% with basal-bolus therapy 1
• Leads to rapid blood glucose fluctuations that exacerbate both hyperglycemia and hypoglycemia 1, 2
• Is associated with widely variable and often ineffectual outcomes 3
• Remains unchanged throughout hospital stays even when control is poor 1, 4

Recommended Alternative Approach

Instead of sliding scale insulin alone, use a basal-bolus insulin regimen with correction doses:

• Basal insulin (long-acting or intermediate-acting) provides background insulin coverage 1
• Nutritional/prandial insulin (rapid-acting analogs like aspart or lispro, or regular insulin) covers meals 1
• Correction-dose insulin (same rapid-acting or regular insulin) supplements when blood glucose exceeds targets 1

Dosing Strategy

• Start with total daily dose of 0.3-0.5 units/kg for insulin-naive patients 2
• Divide dose: 50% as basal insulin once daily, 50% as rapid-acting insulin divided before meals 1, 2
• Use lower doses (0.1-0.15 units/kg/day) for elderly patients or those with poor oral intake 1
• If correction doses are frequently required, increase the scheduled insulin doses accordingly rather than continuing reactive treatment 1

When Sliding Scale Might Be Acceptable

• Mild stress hyperglycemia in patients without established diabetes 2
• As a supplement only to scheduled basal and nutritional insulin, not as monotherapy 1

Common Pitfalls to Avoid

• Never use sliding scale insulin as the sole regimen in patients with established insulin requirements 1
• Avoid premixed insulin formulations in hospitalized patients due to unacceptably high hypoglycemia rates 1
• Do not continue the same sliding scale regimen throughout hospitalization without adjustment when control remains poor 1, 4
• Recognize that approximately 30% of sliding scale insulin administrations have missing documentation regarding execution, timing, or glucose levels 3

Intravenous Insulin for Critical Care

• For critically ill patients, use regular crystalline insulin via continuous intravenous infusion 1
• There is no advantage to using rapid-acting analogs intravenously, as their structural modifications only enhance subcutaneous absorption 1
• Target glucose range of 140-180 mg/dL for most critically ill patients 1