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Sliding Scale Insulin

Division of Endocrinology, New York Hospital Medical Center of Queens, Weill Medical College of Cornell University, Queens, New York

I was surprised and disappointed to see a recommendation for "sliding scale insulin" treatment in Figs. 1 and 2 of the otherwise excellent position statement "Hyperglycemic Crises in Patients with Diabetes Mellitus" (1). I carefully read the text of the article and the accompanying technical review (2), searching in vain for some justification for this recommendation.

I then turned to the literature and performed a Medline search from 1987 to 2000 using the words "sliding scale insulin." The overwhelming consensus in the literature (3,4,5,6,7,8,9,10,11,12,13,14) is that sliding scale insulin is neither efficient nor effective. Sliding scale insulin is an historical artifact dating back to the days of urine testing. As pointedly outlined by Gill and MacFarlane (10), sliding scale is illogical in that it responds to hyperglycemia after it has happened, rather than preventing it, and the sliding scale depends on the clearly inaccurate assumption that insulin sensitivity is uniform among all patients.

In my experience, the major deficit of sliding scale insulin is that it allows the house officer to write an arbitrary insulin regimen and leave the patient’s diabetes management in the hands of floor nursing staff. This is a prescription for hypoglycemia and recurrent diabetic ketoacidosis.

Sliding scale insulin should be discouraged, not endorsed, by the American Diabetes Association.

Footnotes

Address correspondence to Daniel L. Lorber, MD, FACP, CDE, Diabetes Care and Information Center, 59-45 161st St., Flushing, NY 11365. E-mail: Loberdan{at}aol.com.

References

1. American Diabetes Association: Hyperglycemic crises in patients with diabetes mellitus (Position Statement). Diabetes Care 24:154–161, 2001[Free Full Text]
   
2. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM: Management of hyperglycemic crises in patients with diabetes (Technical Review). Diabetes Care 131–153, 2001
   
3. Katz CM: How efficient is sliding-scale insulin therapy? Problems with a ‘cookbook’ approach in hospitalized patients (Review). Postgrad Med 89:46–48, 51–4, 57, 1991
   
4. Gearhart JG, Duncan JL 3rd, Replogle WH, Forbes RC, Walley EJ: Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Prac Res J 14:313–322, 1994[Medline]
   
5. Queale WS, Seidler AJ, Brancati FL: Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Int Med 157:545–552, 1997[Abstract]
   
6. Sawin CT: Action without benefit. Arch Int Med 157:489, 1997[Medline]
   
7. Radack HB: Sliding scale insulin use. Arch Int Med 157:1776, 1997
   
8. DeCherney GS, Maser RE, Lemole GM, Serra AJ, McNicholas KW, Shapira N: Intravenous insulin infusion therapies for postoperative coronary artery bypass graft patients. Del Med J 70:399–404, 1998[Medline]
   
9. Gaster B, Hirsch IB: Sliding scale insulin use and rates of hyperglycemia. Arch Int Med 158:95, 1998[Free Full Text]
   
10. Gill G, MacFarlane I: Are sliding-scale insulin regimens a recipe for diabetic instability? Lancet 349:1555, 1997
    
11. Trachtenbarg DE: Ten errors to avoid in managing type 2 diabetes (Review). Postgrad Med 104:35–43, 1998
    
12. Hirsch IB, Paauw DS, Brunzell J: Inpatient management of adults with diabetes (Review). Diabetes Care 18:870–878, 1995[Medline]
    
13. Genuth SM: The automatic (regular insulin) sliding scale or 2, 4, 6, 8-call H.O. Clin Diabetes 12:40–42, 1994
    
14. Shagan BP: Does anyone here know how to make insulin work backwards? Why sliding-scale insulin coverage doesn’t work. Practical Diabetol 9:1–4, 1990
    

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