How to prescribe a sliding scale insulin?

From the Guidelines

The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, and instead, a basal-bolus insulin regimen is recommended for better glycemic control and to minimize the risk of hypoglycemia and hyperglycemia 1. When prescribing insulin, it's essential to consider the patient's baseline insulin needs, blood glucose targets, and overall diabetes control.

• A basal-bolus insulin regimen, which includes a combination of long-acting insulin (such as insulin glargine or detemir) and rapid-acting insulin (such as insulin lispro, aspart, or glulisine), is the preferred treatment for patients with good nutritional intake 1.
• The basal insulin dose can be started at 0.1-0.2 units/kg per day, and the bolus insulin dose can be adjusted based on the patient's blood glucose readings and insulin sensitivity 1.
• For patients with poor oral intake or those who are receiving nothing by mouth, a basal-plus-correction insulin regimen is recommended, with the basal insulin dose adjusted based on the patient's insulin needs and the correction dose adjusted based on the patient's blood glucose readings 1.
• Regularly reassessing and adjusting the insulin regimen is crucial to achieve optimal glycemic control and minimize the risk of hypoglycemia and hyperglycemia 1. Key considerations when prescribing insulin include:
• Insulin sensitivity: lower doses may be needed for insulin-sensitive patients, such as the elderly or those with renal impairment.
• Insulin resistance: higher doses may be needed for insulin-resistant patients.
• Blood glucose targets: individualize the targets based on the patient's overall health and diabetes control.
• Hypoglycemia and hyperglycemia: regularly monitor the patient's blood glucose readings and adjust the insulin regimen as needed to minimize the risk of these complications.

From the Research

Prescribing Sliding Scale Insulin

To prescribe a sliding scale insulin, consider the following points:

• Sliding-scale insulin has been widely used in treating inpatient hyperglycemia, but its efficacy and safety have been questioned in several studies 2, 3, 4.
• A meta-analysis of randomized controlled trials found that sliding-scale insulin did not provide any benefits in blood glucose control and was accompanied by an increased incidence of hyperglycemic events 2.
• Basal-bolus insulin therapy has been shown to be more effective and safe than sliding-scale insulin in several studies 3, 4.
• When prescribing insulin, consider the type of insulin, such as insulin aspart or insulin lispro, and their effects on postprandial glucose stability 5, 6.

Key Considerations

• The American Diabetes Association recommends the use of basal-bolus insulin therapy over sliding-scale insulin for inpatient glucose control 3, 4.
• Sliding-scale insulin may be associated with a higher incidence of hyperglycemic events and no significant difference in the incidence of severe hypoglycemia compared to basal-bolus insulin therapy 2, 3, 4.
• Insulin lispro has been shown to have a more rapid onset and shorter duration of glucose-lowering activity compared to human regular insulin, making it a suitable option for premeal insulin therapy 6.

Insulin Regimens

• Basal-bolus insulin therapy involves administering a basal insulin dose to cover background glucose levels and a bolus insulin dose to cover meal-related glucose spikes 3, 4.
• Sliding-scale insulin involves administering insulin based on the patient's current blood glucose level, with higher doses given for higher blood glucose levels 2, 3, 4.
• Continuous subcutaneous insulin infusion (CSII) is a type of insulin therapy that involves administering insulin continuously through a pump, and has been shown to be effective in improving postprandial glucose stability 5, 6.