It&#039;s time to abandon the sliding scale

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Applied Evidence

It's time to abandon the sliding scale

J Fam Pract. 2011 May;60(5):266-270

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References

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Calculating a correction dose

If a patientï¿½s blood glucose level rises above a predetermined value, he or she may need an insulin bolus to bring it down. Calculating the supplemental dose is a 2-step process: First, an insulin sensitivity factor (ISF) is calculated; then, the desired blood glucose level is subtracted from the actual blood glucose reading and divided by the ISF.

Step 1: Divide 1700 by the total daily dose (eg, 50 units)

Step 2: Subtract the desired blood glucose level (110 mg/dL) from the actual blood glucose reading (eg, 240 mg/dL) and divide by the ISF

Commentary: For an adult of average size,* an additional 3.8 (or 4) units of rapid-acting insulin should bring the patientï¿½s blood glucose level down to 110 mg/dL. If the elevated blood glucose level occurs at this same time on subsequent days, it is an indication that the dose at the previous meal should be increased.

*An insulin-sensitive child might require less insulin, and an overweight adult might require more. When in doubt, give half of the calculated correction dose and repeat in an hour, if needed.

Other factors that may influence blood glucose levels include the injection site (insulin is absorbed faster when administered in the abdomen vs the leg); the type, or combination, of insulin used, ie, long-acting basal insulin vs intermediate-acting vs (or combined with) short- or rapid-acting insulin; and lifestyle (sedentary, active, very active, or suddenly becoming very active), which also affects the absorption of insulin.²¹

FAST TRACK

Following an algorithm that combines a basal insulin dose with variable dosing of premeal rapid-acting insulin results in less hypoglycemia than a sliding scale system.

CASE After 5 months, Louis and his family returned to their former home. But by then, Louis had an HbA1c of 10.2%. On the advice of the pediatric endocrinologist who had treated him initially, Louis was put back on a pattern management system, using both rapid- and long-acting insulin. Three months later, his HbA1c was down to 7.6%ï¿½close to its previous levelï¿½and he no longer had problems with hypoglycemia.

CORRESPONDENCE
Diana W. Guthrie, PhD, Mid-America Diabetes Associates, 200 South Hillside, Wichita, KS 672111; dguthrie@kumc.edu