Insulin Management for Hospitalized Patients

Introduction to Sliding Scale Insulin

• The American Diabetes Association recommends that sliding scale insulin (SSI) alone should generally not be used as the primary treatment for hospitalized patients with diabetes, except in very limited circumstances such as patients without pre-existing diabetes who have mild stress hyperglycemia, or patients with well-controlled type 2 diabetes managed by diet alone at home who develop mild hyperglycemia during hospitalization 1, 2

When SSI Alone May Be Acceptable

• SSI as monotherapy is appropriate only for patients without diabetes who develop mild stress hyperglycemia during hospitalization, according to the American College of Endocrinology 1, 3
• The Endocrine Society suggests that SSI may be used for well-controlled type 2 diabetes patients (HbA1c <7%) on diet alone or minimal oral therapy at home who have mild hyperglycemia 2, 4

Recommended Alternative: Basal-Plus Approach

• The American College of Endocrinology recommends a basal-plus regimen as superior to SSI alone for most hospitalized patients requiring insulin, with a basal insulin dose of 0.1-0.25 units/kg/day given once daily 1, 3, 5
• The European Association for the Study of Diabetes suggests that correction doses of rapid-acting insulin should be given before meals or every 6 hours if NPO, as part of a basal-plus regimen 1, 3

Safety Considerations

• The American Heart Association notes that basal-bolus regimens provide better glycemic control but carry a 4-6 times higher risk of hypoglycemia compared to SSI alone (RR 5.75 for blood glucose ≤70 mg/dL) 1, 3
• The American Diabetes Association recommends reducing total daily dose by 20% during hospitalization for patients on high-dose insulin at home (≥0.6 units/kg/day) to prevent hypoglycemia 1, 3, 4