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Sliding Scale Insulin Regimen

Sliding-scale Insulin

Sliding-scale Insulin

More evidence needed before final exit? Sliding-scale regular insulin (SSI) in the management of patients with diabetes was the standard practice as early as 1934 (1) and was also used in the hyperglycemic emergency diabetic ketoacidosis (2). These earlier studies used urine glucose for sliding scale, but with demonstration of inaccuracy of urine glucose (3), blood glucose replaced urine glucose for sliding scale in diabetic ketoacidosis (4). SSI is widely used in health institutions (5,6) because it is easy and convenient, but it has the disadvantage of not delivering insulin in a physiologic manner, thereby leading to fluctuations in glycemic levels (7–9). Despite these drawbacks, the use of SSI has survived for >70 years, through many generations of physicians. Retrospective (6,9) and prospective (5) cohort studies, as well as observations and commentaries (10), have concluded that SSI should be discouraged because it has not been shown to be an effective means of achieving much-needed optimal glycemic control in hospitalized patients. However, the issue of SSI has never been settled because of the lack of data on prospective, randomized, controlled studies. Hence, the studies reported in this issue by Umpierrez et al. (11) are a welcome addition based on which future studies could finally settle the controversies of SSI (12). Umpierrez et al. reported on a prospective, randomized, open-label, two-center study in which two groups of relatively similar insulin-naive patients admitted to general medical wards were compared regarding efficacy of basal-bolus insulin (glargine once a day plus glulisine before meals and at bedtime) versus SSI (before each meal and at bedtime if patients were able to eat or every 6 h if they were unable to eat). Although blood glucose was Continue reading >>

Use Of A Standardized Protocol To Decrease Medication Errors And Adverse Events Related To Sliding Scale Insulin

Use Of A Standardized Protocol To Decrease Medication Errors And Adverse Events Related To Sliding Scale Insulin

Go to: Abstract Sliding scale insulin (SSI) is frequently used for inpatient management of hyperglycemia and is associated with a large number of medication errors and adverse events including hypoglycemia and hyperglycemia. Observational before and after study evaluating the impact of implementation of a standardized SSI protocol and preprinted physician order form. Guidelines for the use of SSI were created by an interdisciplinary committee and implemented in non‐intensive care units. In addition, a preprinted physician order sheet was developed which included the guidelines and an option for ordering one of three standardized insulin sliding scales or a patient specific scale. One year after implementation the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient‐days at baseline to 1.2 at 1 year (p = 0.03). The number of hyperglycemia episodes 1 year after implementation decreased from 55.9 to 16.3 per 100 SSI patient‐days. The protocol was readily accepted by hospital staff and was associated with decreased prescribing errors and decreased frequency of hyperglycemia. Keywords: insulin, medication errors, hyperglycemia, practice guidelines Sliding scale insulin (SSI) is commonly used to manage hospitalized patients with and without diabetes mellitus.1,2,3 Monotherapy with SSI often leads to erratic fluctuations of glucose control because it tries to retrospectively “treat” hyperglycemia rather than prospectively “prevent” it.1,4,5,6,7,8,9,10 In the hospital setting, use of supplemental short acting insulin in addition to scheduled basal and preprandial insulin for patients with type 1 diabetes is recommende Continue reading >>

Insulin (medication)

Insulin (medication)

"Insulin therapy" redirects here. For the psychiatric treatment, see Insulin shock therapy. Insulin is used as a medication to treat high blood sugar.[3] This includes in diabetes mellitus type 1, diabetes mellitus type 2, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states.[3] It is also used along with glucose to treat high blood potassium levels.[4] Typically it is given by injection under the skin, but some forms may also be used by injection into a vein or muscle.[3] The common side effect is low blood sugar.[3] Other side effects may include pain or skin changes at the sites of injection, low blood potassium, and allergic reactions.[3] Use during pregnancy is relatively safe for the baby.[3] Insulin can be made from the pancreas of pigs or cows.[5] Human versions can be made either by modifying pig versions or recombinant technology.[5] It comes in three main types short–acting (such as regular insulin), intermediate–acting (such as NPH insulin), and longer-acting (such as insulin glargine).[5] Insulin was first used as a medication in Canada by Charles Best and Frederick Banting in 1922.[6] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[7] The wholesale cost in the developing world is about US$2.39 to $10.61 per 1,000 iu of regular insulin and $2.23 to $10.35 per 1,000 iu of NPH insulin.[8][9] In the United Kingdom 1,000 iu of regular or NPH insulin costs the NHS 7.48 pounds, while this amount of insulin glargine costs 30.68 pounds.[5] Medical uses[edit] Giving insulin with an insulin pen. Insulin is used to treat a number of diseases including diabetes and its acute complications such as diabetic ketoacid Continue reading >>

Sliding Scale Therapy

Sliding Scale Therapy

Sliding scale therapy approximates daily insulin requirements. The term "sliding scale" refers to the progressive increase in pre-meal or nighttime insulin doses. The term “sliding scale” refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. Sliding scale insulin regimens approximate daily insulin requirements. Common sliding scale regimens: Long-acting insulin (glargine/detemir or NPH), once or twice a day with short acting insulin (aspart, glulisine, lispro, Regular) before meals and at bedtime Long-acting insulin (glargine/detemir or NPH), given once a day Regular and NPH, given twice a day Pre-mixed, or short-acting insulin analogs or Regular and NPH, given twice a day The general principles of sliding scale therapy are: The amount of carbohydrate to be eaten at each meal is pre-set. The basal (background) insulin dose doesn’t change. You take the same long-acting insulin dose no matter what the blood glucose level. The bolus insulin is based on the blood sugar level before the meal or at bedtime Pre-mixed insulin doses are based on the blood sugar level before the meal The sliding scale method does not accommodate changes in insulin needs related to snacks or to stress and activity. You still need to count carbohydrates. Sliding scales are less effective in covering a pre-meal high blood sugar, because the high blood glucose correction and food bolus cannot be split. Points To Remember! Sliding scale regimens may include a bedtime high blood sugar correction. As the nighttime scale only considers the amount of insulin required to drop your blood sugar level back into the target range, it should not be used to cover a bedtime snack. When using a sliding scale, eat the same amount of carbohydrat Continue reading >>

Sliding-scale Versus Basal-bolus Insulin In The Management Of Severe Or Acute Hyperglycemia In Type 2 Diabetes Patients: A Retrospective Study

Sliding-scale Versus Basal-bolus Insulin In The Management Of Severe Or Acute Hyperglycemia In Type 2 Diabetes Patients: A Retrospective Study

Abstract Sliding-scale and basal-bolus insulin regimens are two options available for the treatment of severe or acute hyperglycemia in type 2 diabetes mellitus patients. Although its use is not recommended, sliding-scale insulin therapy is still being used widely. The aims of the study were to compare the glycemic control achieved by using sliding-scale or basal-bolus regimens for the management of severe or acute hyperglycemia in patients with type 2 diabetes and to analyze factors associated with the types of insulin therapy used in the management of severe or acute hyperglycemia. This retrospective study was conducted using the medical records of patients with acute or severe hyperglycemia admitted to a hospital in Malaysia from January 2008 to December 2012. A total of 202 patients and 247 admissions were included. Patients treated with the basal-bolus insulin regimen attained lower fasting blood glucose (10.8±2.3 versus 11.6±3.5 mmol/L; p = 0.028) and mean glucose levels throughout severe/acute hyperglycemia (12.3±1.9 versus 12.8±2.2; p = 0.021) compared with sliding-scale insulin regimens. Diabetic ketoacidosis (p = 0.043), cardiovascular diseases (p = 0.005), acute exacerbation of bronchial asthma (p = 0.010), and the use of corticosteroids (p = 0.037) and loop diuretics (p = 0.016) were significantly associated with the type of insulin regimen used. In conclusion, type 2 diabetes patients with severe and acute hyperglycemia achieved better glycemic control with the basal-bolus regimen than with sliding-scale insulin, and factors associated with the insulin regimen used could be identified. Figures Citation: Zaman Huri H, Permalu V, Vethakkan SR (2014) Sliding-Scale versus Basal-Bolus Insulin in the Management of Severe or Acute Hyperglycemia in Type 2 Diabe Continue reading >>

Management Of Hospitalized Patients With Type 2 Diabetes Mellitus

Management Of Hospitalized Patients With Type 2 Diabetes Mellitus

Suboptimal glycemic control in hospitalized patients with type 2 (non–insulin-dependent) diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate. Poor glycemic control can also affect the outcome of the primary illness. If possible, hospitalized diabetic patients should continue their previous antihyperglycemic treatment regimen. Decreased physical activity and the stress of illness often lead to hyperglycemia in hospitalized patients with type 2 diabetes. When indicated, insulin is given either as a supplement to usual therapy or as a temporary substitute. The overall benefit of the traditional sliding-scale insulin regimen has been questioned. Insulin supplementation given according to an algorithm may be a logical alternative. Any antihyperglycemic regimen should be administered and monitored in a manner coincident with the intake of food or other sources of calories. Factors that can alter glycemic control acutely, including specific medical conditions and medications, should be identified and anticipated. Diabetes mellitus is a common secondary diagnosis in hospitalized patients. In 1988, diabetes was one of the diagnoses recorded for 2.8 million patients discharged from hospitals in the United States. Altogether, these patients spent 24.5 million days in hospitals. Diabetes was the secondary diagnosis in more than 80 percent of these patients, with the most frequently listed primary diagnoses being circulatory and cardiovascular diseases.1 Patients with diabetes are hospitalized twice as often as those who do not have this disease, and they are likely to stay in the hospital 30 percent longer.2 Furthermore, annual insurance claims for inpatient care are four times higher amon Continue reading >>

Insulin Sliding Scale

Insulin Sliding Scale

This sliding scale should NOT to be used to treat people with: Diabetic Ketoacidosis (DKA) Hyperglycaemic Hyperosmolar State (HHS) / Hyperosmolar Non-Ketotic Coma (HONC) See individual guidelines for the management of these conditions. This sliding scale can be used to manage glucose levels in people with diabetes mellitus. It can be used in surgical patients with diabetes mellitus undergoing operations however local anaesthetic departments may have their own scales. Prior to using the scale below, discuss with local anaesthetists that they are happy for it to be used. This scale can also be used in medical patients with diabetes mellitus in whom regulation of glucose is deemed important. The principles of the sliding scale are: Desired glucose control is achieved and maintained Avoidance of hypoglycaemia Avoidance of ketosis by providing adequate carbohydrate and insulin Maintenance of fluid and electrolyte balance. Before starting on the sliding scale it is important to specify the target glucose level and whether intravenous fluids are to be given with insulin. Urea and electrolytes should be checked before starting the sliding scale to guide potassium administration. If patient is already on a background insulin (eg Insulatard®, Lantus® or Levemir®), administer at the usual time whilst using sliding scale, unless advised not to by Diabetes team or anaesthetist. Insulin Preparation: Add 50units of soluble insulin (Actrapid® or Humulin S®), drawn up using an insulin syringe, to 50ml of 0.9% sodium chloride in a 50ml syringe. Infuse IV using a syringe pump and adjust according to sliding scale below, which is an initial guide. Please review insulin rate and blood glucose response on a regular basis (see supplementary notes below) and amend if need be to achieve ta Continue reading >>

Sliding Scale Insulin Therapy

Sliding Scale Insulin Therapy

Insulin is the foundation of treatment for many people with diabetes. If you’re a diabetic, your body either can’t produce enough insulin or can’t use insulin efficiently. People with type 1 diabetes, and some with type 2 diabetes, have to take several injections of insulin per day. The insulin keeps blood sugar in a normal range and prevents high blood sugar levels. This can help prevent complications. The amount of insulin you should take can be determined in several different ways: Fixed-Dose Insulin With this method, you take a certain set amount of insulin units at each meal. For example, you may take 6 units at breakfast and 8 at dinner. The numbers don’t change based on your blood sugar readings or the amount of food you eat. While this may be easier for people just starting insulin, it doesn’t account for pre-meal blood sugar levels. It also doesn’t factor in the varying amounts of carbohydrates in a given meal. Carbohydrate to Insulin Ratio In this method, you take a certain amount of insulin for a certain amount of carbohydrates. For example, if your breakfast carb to insulin ratio is 10:1 and you eat 30 grams of carbohydrates, you would take 3 units before breakfast to cover your meal. This method also includes a “correction factor” that accounts for your pre-meal blood sugar. For example, let’s say you want your blood sugar to be under 150 mg/dL before meals, but it’s at 170. If you’ve been told to take 1 unit of insulin for every 50 you’re over, you would take 1 additional unit of insulin before your meal. While this takes a lot of practice and knowledge, people who can manage this method can keep better control of their post-meal blood sugar levels. Sliding-Scale Insulin Therapy (SSI) In the sliding-scale method, the dose is based o Continue reading >>

Sliding Scale Insulin Therapy: How It Works, Doses, Alternatives

Sliding Scale Insulin Therapy: How It Works, Doses, Alternatives

A healthy pancreas releases a burst of insulin as a person begins to eat. This prepares the body for the intake of glucose that is to come. For people who have type 1 diabetes or insulin-deficient type 2 diabetes, these bursts must be recreated through insulin injections either before or after a meal. The sliding scale is one way of working out how much insulin to take before each meal. Most doctors advise against the sliding scale approach. In fact, the American Diabetes Association have pushed for this treatment method to no longer be used. How the sliding scale works The "sliding scale" is actually a chart of insulin dosages. A doctor creates this chart based on how the patient's body responds to insulin, their daily activity, and an agreed-upon carbohydrate intake. As one moves along the chart, insulin dosage changes depending on two factors: Pre-meal blood glucose level This is usually plotted from low to high, down the chart's left-most column. As one slides from top to bottom, insulin dosage increases. This is because more insulin is needed to manage greater amounts of blood glucose. Mealtime This is usually plotted along the chart's top row. As one moves from breakfast to lunch to dinner within the same blood glucose level, dosage may vary. This is because insulin sensitivity, the way the body responds to insulin, can change throughout the day. The fat content of meals can also change through the day, and the doctor may have taken that into consideration. To work out the right dosage using a sliding scale, people should: test their blood glucose level find the matching blood glucose value along the chart's left-hand column slide horizontally along that value's row, until the current meal is reached take a dosage that matches the number where the two values meet Continue reading >>

Evidence For Basal–bolus Insulin Versus Slide Scale Insulin

Evidence For Basal–bolus Insulin Versus Slide Scale Insulin

Abstract Greater understanding of hyperglycemia and its control in non-ICU patients has become ever more urgent given the high and increasing prevalence of diabetes in the general population and, hence, in hospitalized patients. It is well accepted that hyperglycemia in hospitalized patients is common and associated with profound medical consequences, longer lengths of stay, high healthcare costs, and adverse outcomes. It is a marker for poor clinical outcome and mortality. Although evidence that supports intensive glycemic control in critically ill patients is strong, glycemic control is often overlooked or insufficient in patients on general medicine and surgery services. In the face of strong evidence that glycemic control helps to improve outcomes in non-ICU patients, it is critical to consider how best to manage hyperglycemia in medical and surgical patients to develop optimum strategies for maintaining glycemic control. Currently available strategies for glycemic control include sliding-scale insulin and basal–bolus regimens. The principal difference between the two strategies is that sliding-scale insulin does not deliver adequate glycemic control to patients and addresses hyperglycemia after it has occurred, whereas a basal–bolus regimen is directed at preventing hyperglycemia. This paper explores the rationale for and implementation of a basal–bolus insulin regimen in non-critically ill hospitalized patients and in addition reviews best practices for transitions of care and discharge planning. Notes Compliance with Ethics Guidelines This paper was underwritten in part by a grant from Sanofi to the Hospital Quality Foundation to support the writing group’s efforts, including travel. All authors report receiving consulting fees from Sanofi. This article d Continue reading >>

Keeping It Simple With Insulin Regimens

Keeping It Simple With Insulin Regimens

Published in the July 2013 issue of Today’s Hospitalist DESPITE MOUNTING EVIDENCE against sliding scale regular insulin, the strategy continues to be widely used for patients with type 2 diabetes who are hospitalized and need to stop their oral diabetes medications. Many physicians seem to find the alternative “basal bolus “too complicated and too difficult. As a result, experts have been trying to figure out a way to make the basal bolus regimen easier. Drawing on the fact that people tend to eat very little while they are hospitalized, researchers have hit on a relatively simple idea: Use only basal insulin and forget about fast-acting boluses unless needed by individual patients experiencing hyperglycemia in the hospital. This regimen is called basal plus correction, or “basal plus” for short. “I believe this is the simpler way,” explains Guillermo Umpierrez, MD, a professor of medicine and director of endocrinology and diabetes at Grady Health System and Emory University in Atlanta. His research, which was published in the Feb. 22, 2013, issue of Diabetes Care, showed that basal plus “resulted in glycemic control similar to a standard basal bolus regimen.” The study also found that both methods produced better results than sliding scale regular insulin. The multicenter trial randomized 375 patients with type 2 diabetes into three groups: One received sliding scale regular insulin. A second received a basal bolus regimen of glargine once daily and regular doses of rapid-acting glulisine before meals. And patients in the basal plus group received glargine once a day and supplemental doses of glulisine only when regular pre-meal blood sugar checks showed they were hyperglycemic. Besides finding that the basal bolus and basal plus regimens controlled t Continue reading >>

Glycemic Control In Hospitalized Patients Not In Intensive Care: Beyond Sliding-scale Insulin

Glycemic Control In Hospitalized Patients Not In Intensive Care: Beyond Sliding-scale Insulin

Glycemic control in hospitalized patients who are not in intensive care remains unsatisfactory. Despite persistent expert recommendations urging its abandonment, the use of sliding-scale insulin remains pervasive in U.S. hospitals. Evidence for the effectiveness of sliding-scale insulin is lacking after more than 40 years of use. New physiologic subcutaneous insulin protocols use basal, nutritional, and correctional insulin. The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body weight, with one half given as long-acting insulin (the basal insulin dose), and the other one half divided daily over three meals as short-acting insulin doses (nutritional insulin doses). A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy, as opposed to traditional sliding-scale insulin alone. Insulin sensitivity, nutritional intake, and total daily dosing review can alter the physiologic insulin-dosing schedule. Prospective trials have demonstrated reductions in hyperglycemic measurements, hypoglycemia, and adjusted hospital length of stay when physiologic subcutaneous insulin protocols are used. Transitions in care require special considerations and attention to glycemic control medications. Changing the sliding-scale insulin culture requires a multidisciplinary effort to improve patient safety and outcomes. In the United States, the prevalence of diabetes mellitus is now 10.8 percent of adults 20 years and older, and 23.1 percent of adults 60 years and older.1 An estimated one in five U.S. health care dollars is spent caring for someone with diabetes.2 Over the past 10 years, the Agency fo Continue reading >>

Sliding-scale Insulin: An Ineffective Practice

Sliding-scale Insulin: An Ineffective Practice

By Mark D. Coggins, PharmD, CGP, FASCP Aging Well Vol. 5 No. 6 P. 8 In the United States, approximately 26 million people have diabetes mellitus, including 10.9 million adults aged 65 or older.1 The number of those newly diagnosed with diabetes continues to rise, and the Agency for Healthcare Research and Quality reports that over the past decade there has been a 26% increase in the number of patients discharged from hospitals with a primary diagnosis of diabetes. The overall costs related to diabetes treatment place a tremendous burden on the healthcare system, with one in five US healthcare dollars being spent on the condition. Patients with diabetes typically have medical expenses that are 2.3 times higher than those of nondiabetics,1 and families with a child who has diabetes reportedly spend as much as 10% of their income on the disease.2 Beyond the financial cost, diabetes can have a tremendous negative impact on patients and their families due to associated intangibles that are more difficult to measure, such as pain, depression, anxiety, inconvenience, and a lower quality of life. Diabetes Complications The primary goal of diabetes management is to achieve a level of glycemic control that closely mimics that of nondiabetic patients in an effort to prevent the long- and short-term complications associated with the disease. Inadequate blood glucose control over an extended period of time can result in significant long-term complications affecting multiple organ systems with reduced quality of life and increased mortality and morbidity (see Table 1 below). Short-term complications related to the failure to control glycemic levels can result in symptoms associated with periods of hyperglycemia. Issues related to hypoglycemia, when severe and left untreated, can lead Continue reading >>

Designing An Insulin Regimen

Designing An Insulin Regimen

Intensive Insulin Therapy is the standard method of insulin replacement. This page includes a list of what your medical provider should prescribe when designing an insulin regimen for you. The main goal in designing an insulin regimen is to mimic how the body normally releases insulin. If you have type 2 diabetes, there are two main ways to replace insulin. Intensive Insulin Therapy closely mimics the natural insulin production. The second, referred to as Conventional or Sliding Scale Insulin Therapy, more loosely approximates insulin needs. For Intensive Regimens: When you are intensively managed with insulin your medical provider will prescribe an insulin regimen for you, but these are the general principles: Your medical provider should prescribe: A basal or background insulin dose This will be prescribed as one or two injections of long acting insulin, or, if you are using an insulin pump, a daily infusion rate of continuous, small amounts of rapid acting insulin. The background/basal insulin dose is usually the same day to day. With an insulin pump you do have the option of temporarily changing the background rate for a few hours – up or down as needed! A bolus insulin dose to cover the sugar or carbohydrate in your food This will be presented as an insulin to carbohydrate ratio( I:CHO). The I:CHO ratio tells you how many grams of carbohydrate can be covered by one unit of rapid acting insulin. You will need to calculate how much carbohydrate you will eat, and take a dose of insulin that matches the food. A bolus insulin dose to bring your blood sugar back to the normal range A high blood sugar correction bolus insulin dose to bring your blood sugar back into the target range. This will be presented as a correction factor. This correction factor refers to how muc Continue reading >>

Insulin Sliding Scale

Insulin Sliding Scale

Use this sliding scale as an example only Adjust per patient weight and activity or Disability Delays Insulin until Hyperglycemia appears Cover as units per Glucose 50 mg/dl over 150 mg/dl Renal Failure ( Insulin 50% renal excreted) V. Protocol 1: Based on Insulin sensitivity Estimate sensitivity using "rule of 1800" BG change per unit Insulin = 1800/total Insulin daily Example of 60 units/day: 1 unit drops BG 30 mg/dl Protocol (uses rapid acting Insulin , e.g. Lispro ) Using sensitivity, how many units to drop 50 mg/dl For example above, ~1 unit to drop BG 50 mg/dl BG 150-199: 1 unit Bolus Insulin (regular or RA) Based on per carbohydrate when Glucose >60 mg/dl Use for Type I Diabetes , consider for Type II Example: For 3 carbohydrate meal, add 3 units VI. Protocols: Sliding Scales (contact provider if maximum Glucose is exceeded) BG 150-199: 0.5 unit Bolus Insulin (regular or rapid-acting) Schnipper (2009) J Hosp Med 4(1): 16-27 [PubMed] Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Insulin Sliding Scale." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images Related Studies (from Trip Database) Open in New Window Therapeutic or Preventive Procedure (T061) esquema de insulina con escala variable (rgimen/tratamiento), esquema de insulina con escala variable (rgimen/terapia), Sliding scale insulin regime, Sliding scale insulin regime (regime/therapy), esquema de insulina con escala variable Derived from the NIH UMLS ( Unified Medical Language System ) FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Started in 1995, this collection now contains 6546 interlinked topic pag Continue reading >>

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