Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home.
Across existing guidelines, one consistent recommendation is to avoid the sole use of SSI, which was recently added to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Conclusions: B-BI therapy produced significantly lower average FBG levels after 21 days compared with SSI therapy; both groups had similar rates of hypo- and hyperglycemia. Switching to B-BI therapy is feasible, safe, and effective in the LTC setting.
Burden of sliding scale insulin use in elderly long-term care residents with type 2 diabetes mellitus – PubMed
Conclusion: SSI therapy is widely used in LTC facilities and is associated with a high fingerstick burden. SSI regimens are associated with poorer glycemic control but a rate of hypoglycemia similar to that of non-SSI regimens.
Conclusions: SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.
SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s insulin needs nor is it efficient in the long-term care setting. Use of SSI leads to greater patient discomfort and increased nursing time because patients’ blood glucose levels are usually monitored more frequently than may be necessary and more insulin injections may be given. With SSI regimens, patients may be at risk from prolonged periods of hyperglycemia. In addition, the risk of hypoglycemia is a significant concern because insulin may be administered without regard to meal intake. Basal insulin, or basal plus rapid-acting insulin with one or more meals (often called basal/bolus insulin therapy) most closely mimics normal physiologic insulin production and controls blood glucose more effectively.
Diabetes in Older Adults: Consensus Report – PMC
- The use of sliding scale insulin alone for chronic glycemic management is discouraged in inpatient settings as well as in LTC facilities.
- Blood glucose levels consistently over the renal threshold for glycosuria (~180–200 mg/dl, but can vary) increase risk for dehydration, electrolyte abnormalities, urinary incontinence, dizziness, and falls.
- The traditional approach to diabetic management using SSIs is likely to produce hypoglycemic events in elderly diabetics. Increased awareness of the updated AGS 2012 Beers Criteria is critical to improve the quality of medical care for older diabetics.
Other References:
- Clinical Practice Guideline for Diabetes Management in the Post-Acute and Long-Term Care Setting – Journal of the American Medical Directors Association
- Diabetes in Older Adults: Consensus Report – PMC
- American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults – PubMed
- Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association | Diabetes Care | American Diabetes Association
- Sliding Scale Insulin—Time to Stop Sliding | Diabetes | JAMA | JAMA Network
- Sliding scale insulin use: myth or insanity? – PubMed
- The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus – PubMed
- Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy – PubMed
- Glycemic Control and Sliding Scale Insulin Use in Medical Inpatients With Diabetes Mellitus | JAMA Internal Medicine | JAMA Network