What is the protocol for discontinuing SSI (Short-acting insulin) in a patient on long-acting insulin?

Discontinuing Sliding Scale Insulin (SSI) in Patients on Long-Acting Insulin

Do not abruptly stop SSI without first optimizing the basal insulin dose and adding scheduled prandial insulin if the patient has adequate nutritional intake. 1

Step-by-Step Protocol for SSI Discontinuation

1. Assess Current Insulin Requirements

• Calculate total daily insulin needs by reviewing the SSI doses used over the past 24-48 hours and adding them to the current basal insulin dose 1
• Review blood glucose patterns to identify when correction doses are most frequently needed (pre-meal vs. bedtime) 1

2. Optimize Basal Insulin First

• Increase basal insulin dose by incorporating approximately 50-80% of the average daily SSI requirement into the basal dose 1
• Titrate basal insulin based on fasting glucose values, targeting 90-150 mg/dL (5.0-8.3 mmol/L) 1, 2
• Adjust by 2 units every 2-3 days if >50% of fasting values are above goal 1

3. Add Scheduled Prandial Insulin (If Patient Eating)

For patients with adequate oral intake, transition to a basal-bolus regimen rather than relying on SSI alone 1:

• Start prandial insulin at 4 units per meal or 10% of the basal insulin dose 2
• Administer 15 minutes before meals for rapid-acting insulin analogs 2
• Target pre-meal glucose 90-150 mg/dL and post-meal <180 mg/dL 2

4. Implement Limited Correction Insulin Protocol

Replace routine SSI with a simplified correction scale only for hyperglycemia >250 mg/dL 1:

• For glucose >250 mg/dL (>13.9 mmol/L): give 2 units of rapid-acting insulin 1
• For glucose >350 mg/dL (>19.4 mmol/L): give 4 units of rapid-acting insulin 1
• Stop correction scale when not needed daily 1

5. Monitor and Adjust

• Check glucose every 2-4 hours during the transition period 1
• Adjust prandial doses by 1-2 units or 10-15% twice weekly based on post-meal readings 2
• Review and modify the plan if any glucose <70 mg/dL occurs to prevent recurrent hypoglycemia 1

Critical Pitfalls to Avoid

Never use SSI as the sole method of glycemic control in hospitalized patients, as this approach is strongly discouraged and leads to inadequate glucose management 1, 2. The 2024 American Diabetes Association guidelines explicitly state that "sole use of correction or supplemental insulin without basal insulin in the inpatient setting is discouraged" 1.

Do not discontinue SSI without a replacement plan, as this creates a gap in coverage for hyperglycemia 1. The transition must be structured with scheduled insulin doses rather than reactive correction-only approaches 2.

Avoid using rapid or short-acting insulin at bedtime due to nocturnal hypoglycemia risk 2. If correction is needed at bedtime, reduce the dose or reassess the basal insulin regimen 1.

Special Considerations for Poor Oral Intake

For patients with poor oral intake or NPO status, use basal insulin plus correction insulin only (not full basal-bolus) 1. This prevents hypoglycemia while maintaining some glycemic control during periods of reduced nutritional intake 1.