How to stop Short-acting insulin (SSI) in a patient on basal insulin?

How to Eliminate Sliding Scale Insulin (SSI) in Patients on Basal Insulin

Sliding scale insulin (SSI) should not be used as the sole regimen in hospitalized patients with diabetes; instead, transition to a scheduled basal insulin regimen with correctional doses for hyperglycemia >180 mg/dL before meals and at bedtime. 1

Why SSI Must Be Eliminated

The use of sliding scale insulin as a single regimen is unacceptable and results in undesirable hypoglycemia, hyperglycemia, and increased risk of hospital complications compared to basal-bolus regimens. 1

• Multiple randomized multicenter trials have demonstrated that basal insulin analogs provide greater improvement in blood glucose control and reduction in hospital complications compared with SSI alone 1
• SSI-only regimens are associated with worse in-hospital outcomes and should be actively discouraged 1

The Transition Strategy

For Patients with Adequate Oral Intake

Convert to a basal-prandial regimen starting at 0.3 units/kg total daily dose (TDD), with half given as basal insulin once daily and half as rapid-acting insulin before meals. 1

• This basal-bolus approach results in better glycemic control and lower rates of perioperative complications than SSI therapy alone 1
• Calculate the total amount of correctional insulin used in the previous 24 hours from the SSI regimen to help determine the appropriate starting TDD 1

For Patients with Poor or Uncertain Nutritional Intake

Use a reduced starting dose of 0.1-0.15 units/kg/day given mainly as basal insulin, with rapid-acting insulin analogs administered only as correctional coverage for glucose levels >180 mg/dL before meals and at bedtime. 1

• This "basal-plus-correction" approach is safer in elderly patients or those with reduced oral intake due to acute illness, medical procedures, or surgical interventions 1
• The Basal Plus trial demonstrated that basal insulin (glargine) once daily with supplemental rapid-acting insulin (glulisine) for correction of hyperglycemia is effective and safe 1
• This regimen produced similar glycemic control and rates of hypoglycemic events compared with full basal-bolus regimens, but with better outcomes than SSI alone 1

Practical Implementation Steps

Step 1: Calculate Total Daily Dose

• Review the patient's SSI usage over the past 24-48 hours 1
• Add any existing basal insulin dose to the total correctional insulin used 1
• For insulin-naive patients, start with 0.3 units/kg (good nutrition) or 0.1-0.15 units/kg (poor nutrition) 1

Step 2: Distribute the Dose

• Good oral intake: 50% as basal insulin once daily + 50% divided before meals as rapid-acting insulin 1
• Poor/uncertain intake: 70-85% as basal insulin + correctional rapid-acting insulin only for glucose >180 mg/dL 1

Step 3: Discontinue SSI Orders

• Replace SSI with scheduled insulin orders in non-critical care settings 2
• Maintain correctional insulin dosing as part of the structured regimen, not as standalone SSI 1

Critical Pitfalls to Avoid

Never use SSI as the sole method of treatment, as it leads to inadequate glucose control and reactive rather than proactive management. 2

• SSI does not provide basal insulin coverage, leaving patients vulnerable to prolonged hyperglycemia between meals and overnight 1
• The reactive nature of SSI means insulin is given after hyperglycemia has already occurred, rather than preventing it 1
• Do not use rapid or short-acting insulin at bedtime due to nocturnal hypoglycemia risk 2, 3

Special Considerations for Elderly Patients

• For older adults with limited self-management abilities and prandial insulin requirements ≤10 units/dose, consider discontinuing prandial insulin entirely and adding non-insulin agents instead 2
• Simplify regimens in elderly patients to minimize hypoglycemia risk, which can lead to falls, fractures, and cardiovascular events 1
• Accept higher glycemic targets (HbA1c <7.5-8.0%) in elderly patients with multiple comorbidities 1

Monitoring After Transition

• Perform fingerstick blood glucose monitoring before meals and at bedtime to guide correctional doses 1
• Adjust basal insulin dose based on fasting glucose values 1
• Adjust prandial insulin doses based on pre-meal and 2-hour post-meal glucose readings 2, 3
• Titrate doses by 1-2 units or 10-15% every 2-3 days based on glucose trends 2, 3