From the Guidelines
The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged. This approach is reactive rather than preventative, addressing high blood sugar after it occurs rather than preventing it 1. Instead, a basal-bolus regimen that includes both long-acting insulin for baseline coverage and mealtime insulin doses is generally recommended for patients with good nutritional intake.
Key Considerations for Sliding Scale Insulin
- Sliding scale insulin should be individualized based on the patient's insulin sensitivity, weight, and overall health status.
- The regimen involves administering a predetermined dose of rapid-acting insulin according to the measured glucose value before meals and at bedtime.
- For example, a simplified sliding scale might be:
- It's essential to stop the sliding scale when it's not needed daily and to adjust insulin doses and/or add glucose-lowering agents based on fingerstick glucose testing performed before lunch and before dinner, aiming for a goal of 90–150 mg/dL (5.0–8.3 mmol/L) before meals 2, 3.
Adjusting Insulin Therapy
- Every 2 weeks, adjust the insulin dose and/or add glucose-lowering agents based on fingerstick glucose testing.
- If 50% of premeal fingerstick values over 2 weeks are above goal, increase the dose or add another agent.
- If >2 premeal fingerstick values/week are <90 mg/dL (<5.0 mmol/L), decrease the dose of medication 2, 3.
- For simplification of complex insulin therapy, consider changing the timing of basal insulin from bedtime to morning and titrate the dose based on fasting finger-stick glucose test results over a week 4.
Prioritizing Patient Care
Given the most recent and highest quality evidence, the use of sliding scale insulin should be limited and preferably used as supplemental insulin in specific contexts, such as managing hyperglycemia in hospital settings, rather than as the sole treatment for diabetes 1, 2, 3, 4. This approach prioritizes the prevention of high blood sugar and aims to minimize morbidity, mortality, and improve the quality of life for patients with diabetes.
From the Research
Sliding Scale Insulin
- Sliding scale insulin is a treatment approach for managing blood glucose levels, particularly in patients with type 2 diabetes 5.
- However, basal-bolus insulin therapy is often recommended over sliding scale insulin for achieving glycemic control in both inpatient and outpatient settings due to its ability to provide better glycemic control, fewer hypoglycemic events, and less weight gain 5.
- Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter based on patients' self-measured fasting plasma glucose to achieve an individualized target 6.
- The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases, but overbasalization should be avoided 6.
Insulin Analogues
- Insulin analogues, such as insulin aspart, insulin lispro, and insulin glargine, have been developed to mimic the physiologic insulin profiles seen in people without diabetes 7.
- Rapid-acting analogues offer improved postprandial glycemic control and reduced risk of hypoglycemia, while long-acting analogues mimic the insulin secretory profile of basal insulin 7.
- The use of insulin analogues has the potential to significantly improve long-term control over blood glucose in diabetic patients 8.
Glycemic Control
- Glycemic control is crucial to reducing the risk of long-term complications associated with diabetes 8.
- Basal-bolus insulin therapy has been shown to be effective in achieving glycemic control in adult patients with type 2 diabetes mellitus 5.
- The goal of insulin therapy is to achieve an individualized target glucose level, usually between 80-130 mg/dL 6.