From the Guidelines
The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged. According to the most recent and highest quality study 1, a basal-bolus insulin regimen is the preferred treatment for patients with good nutritional intake. This approach helps manage hyperglycemia in hospitalized patients or those with unstable diabetes, though it's more preventative than reactive. For optimal diabetes management, sliding scale insulin should ideally be combined with basal insulin to provide background coverage.
The use of sliding scale insulin can lead to rapid changes in blood glucose levels, exacerbating both hyper- and hypoglycemia, as noted in 1. Instead, a basal-plus-correction insulin regimen is recommended for patients with poor oral intake or those who are receiving nothing by mouth.
In terms of specific guidelines, the American Diabetes Association recommends that premeal glucose targets be set at 90-150 mg/dL (5.0-8.3 mmol/L), with adjustments made every 2 weeks based on fingerstick glucose testing performed before lunch and before dinner 1.
Key points to consider when using insulin therapy include:
- Using patient and drug characteristics to guide decision-making
- Selecting additional agents as needed
- Adjusting insulin dose and/or adding glucose-lowering agents based on fingerstick glucose testing
- Stopping sliding scale when not needed daily
- Avoiding the use of rapid- and short-acting insulin at bedtime
Overall, the goal of insulin therapy should be to achieve optimal glycemic control while minimizing the risk of hypoglycemia and other adverse effects. Basal-bolus insulin regimens are generally preferred over sliding scale insulin alone, as they provide more effective and sustainable glycemic control 1.
From the Research
Standard Sliding Scale Insulin
- The use of standard sliding scale insulin (SSI) is common in long-term care facilities, with approximately 26% of individuals older than 65 years of age in the United States having diabetes 2.
- SSI involves the use of finger-stick blood glucose testing to assess the need for insulin administration based on current blood glucose levels 2.
- However, the sole use of SSI for long-term treatment is not recommended by the American Diabetes Association and other stakeholders in diabetes management 2.
Comparison of Insulin Types
- Studies have compared the efficacy and safety of different types of insulin, including lispro, aspart, and glulisine 3, 4, 5, 6.
- These studies have shown that the different types of insulin have similar abilities to control glycemic variations in patients with type 1 and type 2 diabetes 3, 4, 5, 6.
- For example, a study comparing lispro and aspart found no significant differences in daily dosages of insulin, fasting plasma C-P and 2 h postprandial C-P and insulin, and fructosamine at the baseline and endpoint between the two groups 5.
- Another study comparing glulisine with lispro and aspart found that glulisine had comparable glucose control to lispro/aspart, with similar HbA1c values and total daily insulin doses 6.
Clinical Implications
- The choice of insulin type may depend on individual patient factors, such as age, sex, and diabetes duration 6.
- The use of SSI may be appropriate in certain situations, such as in long-term care facilities where patients may have limited ability to self-manage their diabetes 2.
- However, the American Diabetes Association and other stakeholders recommend that SSI be used in conjunction with other diabetes management strategies, such as basal insulin replacement and lifestyle modifications 2.