Choosing Wisely:

Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home.

Rationale and Comments: 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.
Sponsoring Organizations:
  • American Medical Directors Association
  • Sources:
  • Expert consensus
  • Disciplines:
  • Endocrinologic
  • Geriatric Medicine
  • References: • Sue Kirkman M, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS. Consensus Development Conference on Diabetes and Older Adults. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012 Dec;60(12):2342-56.
    • American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31.
    • Haq J. Insulin sliding scare, does it exist in the nursing home. JAMDA. 2010 Mar;11(3):B14.
    • Hirsch IB. Sliding scale insulin—time to stop sliding. JAMA. 2009;301(2):213-214.
    • American Medical Directors Association. Diabetes management in the long-term care setting clinical practice guideline. Columbia, Md.: AMDA 2008, revised 2010.
    • Pandya N, Thompson S, Sambamoorthi U. The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus. J Am Med Dir Assoc. 2008 Nov;9(9):663-9.
    • Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med. 2007;120(7):563-67.
    • Boyle P, Childs B. A roadmap for improving diabetes management in long-term care communities. Available from: http://www.med-iq.com/index.cfm?fuseaction=courses.overview&cID=591.
    • Golightly LK, Jones MA, Hamamura DH, Stolpman NM, McDermott MT. Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy. Pharmacotherapy. 2006;26(10):1421-32.
    • Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157(5):545-52.

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