Sliding Scale Insulin

  1. Daniel L. Lorber, MD, FACP, CDE
  1. 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.


    • 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}


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