Would blood sugar be better controlled with a sliding scale regimen for a patient with Diabetes Mellitus Type 2 (DMII) currently taking Novolin N (NPH insulin) 18 units before breakfast and 12 units before lunch?

From the Guidelines

A basal-bolus insulin regimen is likely to provide better blood sugar control than a sliding scale insulin regimen or the current fixed Novolin N dosing for Type 2 diabetes. The current fixed intermediate-acting insulin regimen provides baseline coverage, but it doesn't adjust for varying blood glucose levels throughout the day. According to a study published in Diabetes Care 1, basal-bolus insulin therapy utilizing weight-based dosing achieved glycemic control in 68% of patients, compared to only 38% of those receiving sliding-scale insulin alone. A more recent study published in Annals of Internal Medicine 1 also supports the use of basal-bolus insulin therapy, suggesting that dosing adjustments may be necessary in both mealtime and basal insulins, based on blood glucose level and an understanding of the pharmacodynamic profile of each formulation.

Some key points to consider when implementing a basal-bolus insulin regimen include:

• Using a weight-based dosing approach, with doses adjusted based on individual insulin sensitivity
• Combining basal insulin (like Novolin N) for background control with rapid-acting insulin (like Novolin R, Humalog, or NovoLog) for meal-related glucose excursions
• Monitoring blood glucose levels frequently and adjusting insulin doses accordingly
• Educating patients on how to adjust their insulin doses based on their blood glucose readings and individual needs.

Overall, a basal-bolus insulin regimen is likely to provide more effective blood sugar control and improve patient outcomes, as it allows for more precise dosing and adjustments based on individual needs 1.

From the FDA Drug Label

CLINICAL STUDIES The efficacy and safety of LEVEMIR given once-daily at bedtime or twice-daily (before breakfast and at bedtime, before breakfast and with the evening meal, or at 12-hour intervals) was compared to that of once-daily or twice-daily NPH human insulin or once-daily insulin glargine in non-blinded, randomized, parallel studies of 6004 patients with diabetes (3724 with type 1, and 2280 with type 2). In a 24-week, non-blinded, randomized, clinical study (Study E, n=476), LEVEMIR administered twice-daily (before breakfast and evening) was compared to a similar regimen of NPH human insulin as part of a regimen of combination therapy with one or two of the following oral antidiabetes agents (metformin, insulin secretagogue, or α–glucosidase inhibitor) LEVEMIR and NPH similarly lowered HbA1c from baseline (Table 3).

The provided drug label does not directly compare the efficacy of a fixed dose of Novolin N (as ordered) to a sliding scale regimen for blood sugar control in patients with DMII. Therefore, no conclusion can be drawn regarding whether blood sugar would be better controlled through a sliding scale coverage. 2

From the Research

Blood Sugar Control Comparison

• The use of sliding-scale insulin has been compared to other insulin regimens in several studies 3, 4, 5.
• A study published in 2005 found that a 70/30 insulin algorithm was more effective in controlling blood glucose levels than traditional sliding-scale insulin dosing in hospitalized patients with type 2 diabetes 3.
• Another study published in 2009 found that sliding-scale NPH insulin was more effective in controlling blood glucose levels than sliding-scale insulin aspart in continuously tube-fed patients 4.
• However, a meta-analysis published in 2015 found that sliding-scale insulin did not provide any benefits in blood glucose control and was associated with an increased incidence of hyperglycemic events 5.

Sliding Scale Insulin vs Other Regimens

• A study published in 2022 found that switching to a second-generation basal insulin (insulin glargine 300 U/mL) was associated with better persistence, adherence, and HbA1c reduction compared to switching to an alternative first-generation basal insulin analog 6.
• The study also found that the use of insulin glargine 300 U/mL was associated with lower all-cause and diabetes-related hospitalizations and emergency department visits 6.
• A review published in 2008 provided guidance on choosing a second-line insulin regimen for patients with type 2 diabetes, emphasizing the importance of considering patient preferences, lifestyle, and functional capacity 7.

Implications for Blood Sugar Control

• The evidence suggests that sliding-scale insulin may not be the most effective way to control blood glucose levels in patients with type 2 diabetes 3, 5.
• Alternative insulin regimens, such as basal-plus or basal-bolus regimens, may be more effective in achieving better blood glucose control 6, 7.
• Healthcare providers should consider individual patient factors, such as lifestyle and functional capacity, when choosing an insulin regimen 7.