Sliding-scale insulin: an antiquated approach to glycemic control in hospitalized patients

Browning, Linda A.; Dumo, Peter

doi:10.1093/ajhp/61.15.1611

Cited by 55Hyperglycemia and glycemic control in critically ill and hospitalized patientsDiabetes Treatment and ManagementDiabetes Management and Research

Sliding-scale insulin: an antiquated approach to glycemic control in hospitalized patients

Browning, Linda A., Dumo, Peter·2004·American Journal of Health-System Pharmacy

DOI 10.1093/ajhp/61.15.1611

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Linda A. Browning, PHARM.D., Peter Dumo, PHARM.D.; Sliding-scale insulin: An antiquated approach to glycemic control in hospitalized patients, American Journal

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Data from various clinical settings support improved hyperglycaemic control using basal-bolus insulin compared with sliding-scale insulin.
“This is in line with data from various clinical settings that support improved hyperglycaemic control using BBI compared with SSI.53 54”
From Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review (2019) · cites this paper as [53]

Sorted by citations

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial)
Umpierrez, G. E., Smiley, D., Zisman, A., Prieto, L. M., Palacio, A., Ceron, M., Puig, A., & Mejia, R. (2007) · Diabetes Care · doi:10.2337/dc07-0295 · Cited by 671 · see citing works
Sliding Scale Insulin Use: Myth or Insanity?
Umpierrez, G. E., Palacio, A., & Smiley, D. D. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2006.05.070 · Cited by 144 · see citing works
Sliding Scale Insulin—Time to Stop Sliding
Hirsch, I. B. (2009) · JAMA · doi:10.1001/jama.2008.943 · Cited by 136 · see citing works
“A MEDLINE search of 52 trials from 1966 to 2003 did not reveal even 1 report of benefit from SSI.12 In fact, the concerns of this nonsensical practice were noted 45 years ago.13 So why does the practice of SSI continue to flourish in academic medical centers and community hospitals?”
BackgroundInfluential
Understanding hypoglycemia in hospitalized patients
Hulkower, R., Pollack, R. M., & Zonszein, J. (2014) · Diabetes Management · doi:10.2217/dmt.13.73 · Cited by 88 · see citing works
European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke
Fuentes, B., Ntaios, G., Putaala, J., et al. (2017) · European Stroke Journal · doi:10.1177/2396987317742065 · Cited by 74 · see citing works
“There is also a general recommendation against the use of SC sliding-scale insulin or the so-called correction insulin based on the use of rapid-acting insulin in critically ill patients as the sole regimen as it is not evidence based and ineffective in the majority of the patients.(52,53) On the other side, noninsuli…”
Background
Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin
Donihi, A. C. (2006) · BMJ Quality & Safety · doi:10.1136/qshc.2005.014381 · Cited by 63 · see citing works
Continuous Insulin Infusion: When, Where, and How?
Kelly, J. L. (2014) · Diabetes Spectrum · doi:10.2337/diaspect.27.3.218 · Cited by 50 · see citing works
Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin.
Nau, K. C., Lorenzetti, R. C., Cucuzzella, M. T., Devine, T., & Kline, J. M. (2010) · PubMed · Cited by 44 · see citing works
Insulin Infusion Protocols for Critically ILL Patients: A Highlight of Differences and Similarities
Nazer, L. H., Chow, S. L., & Moghissi, E. S. (2007) · Endocrine Practice · doi:10.4158/ep.13.2.137 · Cited by 43 · see citing works
Basal–bolus insulin versus sliding‐scale insulin for inpatient glycaemic control: a clinical practice comparison
Roberts, G. W., Aguilar‐Loza, N., Esterman, A., Burt, M. G., & Stranks, S. N. (2012) · Medical Journal of Australia · doi:10.5694/mja11.10853 · Cited by 42 · see citing works
Transitioning safely from intravenous to subcutaneous insulin
Kreider, K. E., & Lien, L. F. (2015) · Current Diabetes Reports · doi:10.1007/s11892-015-0595-4 · Cited by 36 · see citing works
Pharmacists’ role in ensuring safe and effective hospital use of insulin
Cohen, M. R. (2010) · American Journal of Health-System Pharmacy · doi:10.2146/ajhp100173 · Cited by 34 · see citing works
Insulin infusion protocol for critical care units
Dilkhush, D., Lannigan, J., Pedroff, T., et al. (2005) · American Journal of Health-System Pharmacy · doi:10.2146/ajhp040590 · Cited by 30 · see citing works
Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review
Tatalovic, M., Lehmann, R., Cheetham, M., Nowak, A., Battegay, E., & Rampini, S. K. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-028914 · Cited by 27 · see citing works
“This is in line with data from various clinical settings that support improved hyperglycaemic control using BBI compared with SSI.(53) 54 Gerards et al(37) corroborates that SSI delivers poorer control compared with IMI when used as an addition to the routine DM regimen.”
Result
Pathophysiology and management strategies for hyperglycemia for patients with acute illness during and following a hospital stay
Dombrowski, N. C., & Karounos, D. G. (2012) · Metabolism · doi:10.1016/j.metabol.2012.07.020 · Cited by 27 · see citing works
“Notably, there is a lack of evidence supporting its safety or effectiveness, and no evidence that SSI improves clinical outcomes [30].”
Burden of Sliding Scale Insulin Use in Elderly Long‐Term Care Residents with Type 2 Diabetes Mellitus
Pandya, N., Wei, W., Meyers, J., et al. (2013) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12547 · Cited by 25 · see citing works
“SSI regimens are widely recognized as a nonoptimal approach to blood glucose control in individuals with T2DM and are discouraged in ADA and AMDA clinical guidelines.(11,12,14) Despite this, SSI use continues to be widespread in LTC facilities.”
BackgroundMethod
Hyperglycemia management in the hospital setting
Hassan, E. (2007) · American Journal of Health-System Pharmacy · doi:10.2146/ajhp070102 · Cited by 24 · see citing works
Management of Inpatient Hyperglycemia in Noncritically Ill Patients
Lansang, M. C., & Umpierrez, G. E. (2008) · Diabetes Spectrum · doi:10.2337/diaspect.21.4.248 · Cited by 21 · see citing works
Insulin Therapy in the Elderly Patient With Diabetes
Tanwani, L. K. (2011) · The American Journal of Geriatric Pharmacotherapy · doi:10.1016/j.amjopharm.2011.02.006 · Cited by 20 · see citing works
Sliding scale insulin: will the false idol finally fall?
Cheung, N. W., & Chipps, D. R. (2010) · Internal Medicine Journal · doi:10.1111/j.1445-5994.2010.02231.x · Cited by 16 · see citing works
Things We Do For No Reason: Sliding‐Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients
Ambrus, D. B., & O’Connor, M. J. (2018) · Journal of Hospital Medicine · doi:10.12788/jhm.3109 · Cited by 15 · see citing works
Sliding Scale Insulin vs Basal-Bolus Insulin Therapy in Long-Term Care: A 21-Day Randomized Controlled Trial Comparing Efficacy, Safety and Feasibility
Dharmarajan, T. S., Mahajan, D., Zambrano, A., Agarwal, B., Fischer, R., Sheikh, Z., Lebelt, A. S., Patel, M., Wester, R., Madireddy, N. P., et al. (2015) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2015.08.015 · Cited by 16 · see citing works
In-hospital treatment of hyperglycemia: effects of intensified subcutaneous insulin treatment
Elinav, H., Wolf, Z., Szalat, A., Bdolah‐Abram, T., Gläser, B., Raz, I., & Leibowitz, G. (2007) · Current Medical Research and Opinion · doi:10.1185/030079907x178748 · Cited by 12 · see citing works
An inpatient hypoglycemia committee: development, successful implementation, and impact on patient safety.
Pasala, S., Dendy, J. A., Chockalingam, V., & Meadows, R. Y. (2013) · Europe PMC (PubMed Central) · Cited by 11 · see citing works
What are the disadvantages of sliding-scale insulin?
Michota, F. A. (2007) · Journal of Hospital Medicine · doi:10.1002/jhm.183 · Cited by 11 · see citing works
Hyperglycemia Management in the Hospital: About Glucose Targets and Process Improvements
Juneja, R. (2008) · Postgraduate Medicine · doi:10.3810/pgm.2008.11.1937 · Cited by 11 · see citing works
Hyperglycemia Management in the Hospital: The Pharmacists Role
Eppley, M. A., & Serr, G. (2009) · Hospital Pharmacy · doi:10.1310/hpj4407-594 · Cited by 10 · see citing works
“Also, SSI orders written at admission often are not adjusted during the entire hospital stay(23,24) and may be associated with an increased LOS.(23,25) The use of SSI places patients with type 1 diabetes at high risk for ketoacidosis if a basal insulin is not added.”
Background
Predicting Inpatient Glucose Levels and Insulin Dosing by Machine Learning on Electronic Health RecordsPreprint
Liu, X., Jankovic, I., & Chen, J. H. (2020) · medRxiv · doi:10.1101/2020.03.02.20029017 · Cited by 10 · see citing works
Comparison on Efficacy and Safety of Three Inpatient Insulin Regimens for Management of Non-Critical Patients with Type 2 Diabetes
Said, E., Farid, S. F., Sabry, N. A., & Fawzi, M. (2013) · Pharmacology &amp Pharmacy · doi:10.4236/pp.2013.47080 · Cited by 9 · see citing works
“SSI is a reactive response to hyperglycemia [7,32] and is based on illogical assumption that insulin sensitivity is the same for all patients [20].”
Background
Continuous Intravenous Insulin: Ready for Prime Time
D’Hondt, N. (2008) · Diabetes Spectrum · doi:10.2337/diaspect.21.4.255 · Cited by 9 · see citing works
Barriers to Implementing an Insulin Order Form In a Non-ICU Medical Unit.
Arif, S. A., & Escaño, A. K. (2010) · PubMed Central · Cited by 8 · see citing works
Effectively Identifying the Inpatient With Hyperglycemia to Increase Patient Care and Lower Costs
Mabrey, M., McFarland, R., Young, S. L., Cooper, P. L., Chidester, P., & Rhinehart, A. S. (2014) · Hospital Practice · doi:10.3810/hp.2014.04.1098 · Cited by 8 · see citing works
Use of basal insulin and the associated clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus: a retrospective chart review study
Davis, K. L., Wei, W., Meyers, J., Kilpatrick, B. S., & Pandya, N. (2014) · Clinical Interventions in Aging · doi:10.2147/cia.s65411 · Cited by 8 · see citing works
Ensuring optimal insulin utilization in the hospital setting: Role of the pharmacist
Kelly, J. L. (2010) · American Journal of Health-System Pharmacy · doi:10.2146/ajhp100172 · Cited by 8 · see citing works
Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon
Khoury, G. E., Mansour, H., Kabbara, W. K., Chamoun, N. R., Atallah, N., & Salameh, P. (2018) · Current Diabetes Reviews · doi:10.2174/1573399814666180119142254 · Cited by 8 · see citing works
Evidence-based therapeutics for hyperglycemia in hospitalized noncritically ill patients
Gracia‐Ramos, A. E., Carretero‐Gómez, J., Mendez, C. E., & Carrasco-Sánchez, F. J. (2021) · Current Medical Research and Opinion · doi:10.1080/03007995.2021.1997288 · Cited by 6 · see citing works
Optimizing Inpatient Glycemic Control with Basal-Bolus Insulin Therapy
Pollom, R. D. (2010) · Hospital Practice · doi:10.3810/hp.2010.11.346 · Cited by 5 · see citing works
Relationship Between Standardized Glycemic Protocols and Healthcare Cost
Coto, J. A., Yehle, K. S., & Foli, K. J. (2014) · Clinical Nursing Research · doi:10.1177/1054773814539003 · Cited by 5 · see citing works
“Sliding scale insulin (SSI) dosing does not support proper glycemic control of the diabetic patient (Browning & Dumo, 2004); however, basal-bolus insulin administration provides optimal management of hyperglycemia in DM-2 patients (Umpierrez et al., 2007; Umpierrez et al., 2011).”
Background
In Hospitalized Patients
Oyen, L. J. (2007) · Cited by 4 · see citing works
Comparison of Prevailing Insulin Regimens at Different Time Periods in Hospitalized Patients: A Real-World Experience from a Tertiary Hospital
Moon, S. J., Choe, H. J., Kwak, S. H., Jung, H. S., Park, K. S., & Cho, Y. M. (2021) · Diabetes & Metabolism Journal · doi:10.4093/dmj.2021.0065 · Cited by 3 · see citing works
“This approach is destined to result in suboptimal glycemic control as it overlooks anticipated hyperglycemia, necessitating the implementation of a more proactive scheduled insulin protocol [11-15].”
Impact of a New Insulin Chart on Hospitalised Patients with Diabetes
Lehnbom, E. C., Welch, S. A., Ludington, J. E., et al. (2009) · Journal of Pharmacy Practice and Research · doi:10.1002/j.2055-2335.2009.tb00703.x · Cited by 3 · see citing works
Insulin Use in the Hospital: An Evolving Therapeutic Paradigm
Reynolds, L. R. (2008) · Laboratory Medicine · doi:10.1309/871fw3daaqfceuu9 · Cited by 3 · see citing works
Pilot and Revision of a Basal-Bolus Dosing Guideline for the Management of Hyperglycemia in Noncritically Ill Adult Patients
Fahim, G., Davanos, E., Muzykovsky, K., & Rubin, R. F. (2014) · Journal of Pharmacy Practice · doi:10.1177/0897190014544818 · Cited by 2 · see citing works
“Scheduled basal, nutritional, and correctional insulin components are preferred for treatment, as this regimen closely mimics normal insulin physiology as opposed to the widely used sliding scale insulin (SSI) method, which is a reactive approach for the treatment of hyperglycemia.(5) The efficacy of a basal-bolus dos…”
Method
Practice of hyperglycaemia control in intensive care units of the Military Hospital, Sudan—Needs of a protocol
El‐Raheem, G. O. H. A., Abdallah, M. M. A., & Noma, M. (2022) · PLoS ONE · doi:10.1371/journal.pone.0267655 · Cited by 1 · see citing works
“The dominant hyperglycaemia control method in both surgical and mixed ICUs was sliding scale, which stood as the standard practice of our study participants while this method was discouraged [17,19,34,36,37].”
Method
Clinical Outcomes Associated with Use of Subcutaneous Sliding Scale Insulin Compared to Other Insulin Regimens in Hospitalized Patients
Alfehaid, L., Alotaibi, A. S., Alanazi, A. S., et al. (2018) · International Journal of Clinical Medicine · doi:10.4236/ijcm.2018.94023 · Cited by 1 · see citing works
“Furthermore, while SSI is used for treating hyperglycemia, it does not prevent hyperglycemia from occurring in the future, so it is not a proactive approach but rather reactive [14].”
Improving Management of Type 2 Diabetes Mellitus in Hospitalized Adults: A Quality Initiative
Wahlberg, E. A., Muthukrishnan, P., Burnett, M., Barrett, K. V., Gilbert, M. P., & Repp, A. B. (2021) · Journal for Healthcare Quality · doi:10.1097/jhq.0000000000000298 · Cited by 1 · see citing works
Evaluation of a Standardized Sliding Scale Insulin Preprinted Order
Wilbur, K., & Yu, C. H. (2007) · Journal of Pharmacy Technology · doi:10.1177/875512250702300302 · Cited by 1 · see citing works
Predictors of sliding scale insulin use by housestaff physicians in the management of hospitalized patients with diabetes mellitus
McFarlane, S. I., Gliwa, A., Bubb, C., et al. (2006) · Therapy · doi:10.2217/14750708.3.3.395
Continuous Intravenous Insulin: An Evaluation in Bariatric Patients Outside of the Intensive Care Unit
Mabrey, M., Vorderstrasse, A. A., Champagne, M. T., & Pickett, L. C. (2012) · Bariatric Nursing and Surgical Patient Care · doi:10.1089/bar.2012.9956
“29 From this review, they concluded there were no clinical trials to demonstrate the beneﬁt and, as such, SSI is an inappropriate approach to blood glucose control in diabetic patients.”
Reformulación de consensos pos-NICE-SUGAR en el manejo de hiperglicemia intrahospitalaria para el médico internista.
Ugaz-Zegarra, M. (2011) · Dialnet (Universidad de la Rioja)
Impact of an educational program to improve glycemic control in patients hospitalized in Internal Medicine departments Impacto de un programa educativo para mejorar el control de la glucemia en pacientes hospitalizados en servicios de medicina interna
Ena, J., Casañ, R. G., Lozano, T., et al. (2008)
The association between hypoglycemia and mortality may be more specific to 'spontaneous hypoglycemia' as opposed to iatrogenic hypoglycemia, implying that hypoglycemia may be a biomarker for poor prognosis rather than a true cause of mortality.
Hulkower, R., Pollack, R. M., & Zonszein, J. (2014)
Insulin for Inpatients in Noncritical Care Settings
Ismail‐Beigi, F. (2010) · Endocrine Practice · doi:10.1016/s1530-891x(20)42861-7
King Fahad National Guard Hospital Internal Medicine Consultation Service: Contributing Co-Morbidities and Reasons for Consultation
Alasmari, F. A., Alenezi, F. Z., Alaskar, N. M., et al. (2011) · Saudi Journal of Internal Medicine · doi:10.32790/sjim.2011.1.1.6
“It is worth mentioning, that the use of sliding scale subcutaneous insulin regimes for inpatient glucose control is not recommended([6,8]) and that a dedicated “diabetes-team” consultation service seems to lead to a shorter hospital-stay([9]).”
Background
Hyperglycemia In Hospitalized Patients
Yavuz, D. G., Yazıcı, D., Özcan, S., Tarçın, Ö., Deyneli, O., & Akalın, S. (2013) · Marmara medical journal · doi:10.5472/mmj.2013.02703.1

Authors: Browning, L. A., & Dumo, P.
Affiliations: Detroit Medical Center (US)
Wayne State University (US)
Corresponding author: Dumo, Peter
Venue: American Journal of Health-System Pharmacy
Publisher: Oxford University Press (OUP)
Published: 2004-08-01
Volume: 61
Issue: 15
Pages: 1611-1614
ISSN: 1079-2082 (ISSN-L)
1535-2900
DOI: 10.1093/ajhp/61.15.1611
OpenAlex: W1880138407
Cited by: 55
References: 0
Citations by year: 2022: 1 · 2021: 3 · 2020: 1 · 2019: 1 · 2018: 3 · 2017: 1 · 2015: 2 · 2014: 7 · 2013: 4 · 2012: 3
FWCI: 2.33
Type: journal article
Language: en
Open access: closed
Locations: American Journal of Health-System Pharmacy (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Keywords: sliding scale insulin, glycemic control, hospitalized patients, intensive care unit, critically ill patients, insulin dose, hyperglycemia management
MeSH terms: Blood Glucose, Clinical Trials as Topic, Drug Administration Schedule, Humans, Hyperglycemia, Hypoglycemic Agents, Insulin, Pharmacy Service, Hospital

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Sliding-scale insulin: an antiquated approach to glycemic control in hospitalized patients

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