When should sliding scale insulin (SSI) therapy be discontinued in a patient with a history of hyperglycemia?

When to Discontinue Sliding Scale Insulin

Sliding scale insulin (SSI) as monotherapy should be discontinued immediately upon admission or recognition in hospitalized patients with diabetes, as it is strongly discouraged by the American Diabetes Association and associated with inferior glycemic control and increased complications. 1

Primary Recommendation: Discontinue SSI Monotherapy Now

The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged (A-level evidence). 1 SSI should be replaced with a scheduled basal-bolus or basal-plus insulin regimen as the foundation of inpatient diabetes management. 2

Why SSI Must Be Discontinued

• SSI is a reactive approach that treats hyperglycemia after it occurs, leading to rapid blood glucose fluctuations and clinically significant hyperglycemia, with only 38% of patients achieving mean blood glucose <140 mg/dL compared to 68% with basal-bolus regimens. 2

• SSI monotherapy results in significantly higher mean blood glucose levels (14.8 mg/dL higher) and increased incidence of hyperglycemic events compared to basal-bolus insulin regimens. 3, 4

• SSI is associated with increased hospital complications, including postoperative wound infections and acute renal failure. 2

• Meta-analysis of 11 randomized controlled trials involving 1,322 patients demonstrated that SSI provided no benefits in blood glucose control but was accompanied by increased hyperglycemic events. 3

What to Replace SSI With

For Patients with Good Oral Intake:

• Initiate basal-bolus insulin regimen with basal, nutritional, and correction components (A-level evidence). 1

• Starting dose: 0.3-0.5 units/kg/day total daily dose, with 50% allocated to basal insulin (once daily) and 50% to rapid-acting prandial insulin (divided before meals). 2, 5

• For insulin-naive patients or those on low home doses, use 0.3 units/kg/day. 2

• For patients on higher home insulin doses (≥0.6 units/kg/day), reduce total daily dose by 20% during hospitalization to prevent hypoglycemia. 2, 6

For Patients with Poor or No Oral Intake (NPO):

• Use basal-plus-correction insulin regimen (A-level evidence). 1

• Starting dose: 0.1-0.25 units/kg/day of basal insulin plus correction doses of rapid-acting insulin for blood glucose >180 mg/dL. 5, 6

• This approach is preferred for fasting patients or those undergoing procedures to minimize hypoglycemia risk. 2

Limited Acceptable Uses of SSI (As Adjunct Only, Never Monotherapy)

SSI may be acceptable only as supplemental correction insulin in these specific scenarios:

• Mild stress hyperglycemia without pre-existing diabetes 6

• Well-controlled diabetes (HbA1c <7%) on minimal home therapy with only mild hyperglycemia during hospitalization 6

• Patients who are NPO with no nutritional replacement and only mild hyperglycemia 6

• Patients who are new to steroids or tapering steroids 6

Even in these scenarios, SSI should be used as correction doses alongside scheduled basal insulin, not as monotherapy. 2, 6

Critical Safety Considerations When Transitioning

• The basal-bolus approach carries 4-6 times higher hypoglycemia risk than SSI alone (risk ratio 5.75,95% CI 2.79-11.83 for blood glucose ≤70 mg/dL). 2

• Implement hospital-wide hypoglycemia protocols for glucose <70 mg/dL before transitioning. 2

• Review and adjust the treatment regimen after any glucose <70 mg/dL episode. 2

• For frail, elderly patients or those with acute kidney injury, reduce starting dose to 0.15 units/kg/day to minimize hypoglycemia risk. 5

Stratified Approach by Hyperglycemia Severity

Mild Hyperglycemia (Blood Glucose <200 mg/dL):

• Start low-dose basal insulin (0.1 units/kg/day) plus correction doses of rapid-acting insulin before meals or every 6 hours. 5

Moderate Hyperglycemia (Blood Glucose 201-300 mg/dL):

• Start basal insulin at 0.2-0.3 units/kg/day plus correction doses before meals. 5

Severe Hyperglycemia (Blood Glucose >300 mg/dL):

• Initiate full basal-bolus regimen at 0.3 units/kg/day total daily dose, with 50% as basal insulin and 50% as prandial insulin. 5

Common Pitfalls to Avoid

• Never continue SSI monotherapy throughout hospital stay without modification, even when control remains poor—this is the most common error. 7

• Avoid premixed insulin formulations (70/30) in the hospital setting, as they cause threefold higher hypoglycemia rates compared to basal-bolus regimens. 5

• Do not use SSI for patients with type 1 diabetes—they require scheduled basal insulin at all times. 6

• If correction doses are frequently required, increase the scheduled insulin doses accordingly rather than continuing reactive SSI approach. 6