What immediate action should be taken for a patient on a sliding scale of insulin (Regular Insulin or Humalog (insulin lispro)) with a bedtime blood glucose level of hyperglycemia?

Immediate Action for Bedtime Blood Glucose of 12.3 mmol/L (221 mg/dL) on Sliding Scale Insulin

Yes, administer correction insulin according to your sliding scale protocol immediately, but recognize that sliding scale insulin alone is fundamentally inadequate and must be replaced with a scheduled basal-bolus regimen as soon as possible. 1

Immediate Bedtime Management

Give Correction Dose Now

• Administer the correction dose of rapid-acting insulin (Regular or Humalog) as specified in your sliding scale for a glucose of 221 mg/dL 1
• For bedtime specifically, use caution with correction doses to avoid nocturnal hypoglycemia—consider reducing the calculated correction by 25-50% if the patient has no planned food intake 2

Critical Safety Consideration

• Bedtime correction insulin carries higher risk of nocturnal hypoglycemia than daytime corrections 2, 3
• If using Humalog (lispro), its rapid onset (0-15 minutes) and shorter duration make it preferable to Regular insulin at bedtime, as it reduces overnight hypoglycemia risk 3
• Ensure the patient has no contraindications to correction (recent hypoglycemia, declining oral intake, acute illness) 1

The Fundamental Problem: Sliding Scale Monotherapy Must Stop

Why This Regimen Is Failing

• Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and provides no benefit for glycemic control 1
• This "reactive" approach treats hyperglycemia after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1, 4
• Meta-analysis of 1,322 patients showed sliding scale insulin resulted in significantly higher mean blood glucose (27.33 mg/dL higher) and increased hyperglycemic events compared to scheduled insulin regimens 4
• When used alone, sliding scale regimens are associated with a 3-fold higher risk of hyperglycemic episodes compared to no pharmacologic treatment 5

Immediate Transition Required

• This patient needs scheduled basal insulin starting tomorrow, not continued reliance on sliding scale alone 1
• The bedtime glucose of 221 mg/dL indicates persistent hyperglycemia requiring basal insulin coverage 1

Recommended Insulin Regimen Starting Tomorrow Morning

Initiate Basal Insulin

• Start Lantus (insulin glargine) at 10 units once daily or 0.1-0.2 units/kg body weight administered at the same time each day 1
• For patients with more severe hyperglycemia (which this bedtime reading suggests), consider starting at the higher end: 0.2 units/kg/day 1, 6

Titration Protocol

• Increase basal insulin by 4 units every 3 days if fasting glucose remains ≥180 mg/dL (10 mmol/L) 1, 6
• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL (7.8-9.9 mmol/L) 1, 6
• Target fasting plasma glucose: 80-130 mg/dL (4.4-7.2 mmol/L) 1

Maintain Correction Insulin as Adjunct Only

• Continue correction doses of rapid-acting insulin as a supplement to scheduled basal insulin, not as monotherapy 1
• Correction insulin addresses acute hyperglycemic excursions but does not replace the need for basal coverage 1, 6

Monitoring Requirements

Daily Assessments

• Check fasting blood glucose every morning during titration 1, 6
• Monitor for hypoglycemia triggers: reduced oral intake, emesis, new NPO status, unexpected interruption of feedings 1
• If hypoglycemia occurs, reduce basal dose by 10-20% immediately 1, 6

When to Add Prandial Insulin

• If after 3-6 months of basal insulin optimization, fasting glucose reaches target but HbA1c remains above goal, add prandial insulin 1, 6
• When basal insulin exceeds 0.5 units/kg/day without achieving targets, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone 1, 6

Common Pitfalls to Avoid

Do Not Continue Sliding Scale Monotherapy

• 75% of hospitalized patients who experienced hypoglycemia had no basal insulin dose adjustment before the next administration—this demonstrates the danger of reactive-only approaches 6
• Sliding scale insulin provides no glycemic benefit and increases hyperglycemic events 4, 5

Do Not Delay Basal Insulin Initiation

• Prolonged exposure to hyperglycemia increases complication risk and hospital length of stay 1
• Structured insulin regimens with basal, nutritional, and correction components are the preferred treatment 1

Ensure Proper Foundation Therapy

• Continue metformin unless contraindicated when adding insulin therapy 1, 6
• Metformin reduces total insulin requirements and provides complementary glucose-lowering effects 6