Sliding Scale Insulin for Diet-Controlled Type 2 Diabetes Inpatients

Assessment of Inpatient Insulin Requirements

The American Diabetes Association recommends that patients with diet-controlled diabetes who manage their condition without medications at home typically have adequate beta-cell function and do not require scheduled basal insulin during hospitalization 3, 4
The American College of Endocrinology suggests that the use of sliding scale insulin alone may be appropriate for patients with mild stress hyperglycemia or those with good metabolic control treated with diet alone at home 1
Current guidelines strongly discourage the sole use of sliding scale insulin for patients with established insulin requirements, but this recommendation does not necessarily apply to diet-controlled patients 3, 5

For diet-controlled type 2 diabetes patients, the American Association of Clinical Endocrinologists recommends beginning with sliding scale insulin (correctional insulin) alone to treat hyperglycemia after it occurs 1, 2
The Endocrine Society suggests monitoring blood glucose before meals and at bedtime (or every 4-6 hours if NPO) 6
The American Diabetes Association recommends adding basal insulin only if blood glucose levels consistently remain above 180 mg/dL despite correctional insulin 1, 2

Guidelines recognize that sliding scale insulin alone may be appropriate for patients without diabetes or those with mild stress hyperglycemia 1
For patients with good metabolic control treated with diet alone at home, the American College of Endocrinology recommends sliding scale insulin alone as the initial approach 1, 2
The risk of hypoglycemia with basal-bolus insulin is 4-6 times higher than with sliding scale insulin therapy alone, making the latter safer for patients who don't require insulin at home 1

Automatically placing all diabetic patients on basal-bolus insulin regimens regardless of their outpatient regimen can lead to unnecessary hypoglycemia 4, 1
The American Association of Clinical Endocrinologists advises against continuing the same sliding scale regimen throughout hospitalization without modification despite poor control 5, 2
The Endocrine Society recommends avoiding the use of premixed insulin therapy (70/30) in the hospital setting, which has been associated with unacceptably high rates of hypoglycemia 4, 8

If the patient develops persistent hyperglycemia (>180 mg/dL) despite sliding scale insulin, the American Diabetes Association recommends adding a low dose of basal insulin (0.1-0.25 U/kg/day) 4, 7
For patients with renal impairment, the American College of Endocrinology suggests using lower doses of insulin due to increased risk of hypoglycemia 9

For diet-controlled patients who required only sliding scale insulin during hospitalization with good glycemic control, the American Association of Clinical Endocrinologists recommends that they can typically return to diet management alone upon discharge 3
If basal insulin was required during hospitalization but the patient was previously diet-controlled, the Endocrine Society advises reassessing the need for continued medication before discharge 3, 6