Sliding Scale Insulin

Thanks to Sarah Taylor, Pharm.D. for her guest post tonight!

Sliding scale insulin, or SSI, is commonly seen in nursing homes, however, it might suprise most healthcare workers to hear that this form of diabetes “management” is not considered best practice. Challenges do exist especially in geriatrics as far as frequency of meals, refusing meals, possible dementia, etc., but the reason why SSI is not considered to be very beneficial to a resident is because it is “reactive” instead of “proactive” management of diabetes- i.e. we randomly test a blood sugar and play catch-up by administering an extra dose of rapid acting insulin (Humalog/Novolog)… but we never actually address the reason for hyperglycemia (high blood sugar). In addition, SSI is actually on the BEERS criteria, a list of potentially inappropriate medications in the elderly, due to risk of hypoglycemia (low blood sugar). Just to give an example, at one facility I was recently at a resident had an order for SSI administered four times daily, and in the first 10 days of that month out of 40 possible scheduled doses, approximately 20 times the SSI had to be held due to resident having too low of blood sugars to administer SSI and the rest of the doses only 1 unit needed to be given. The first thought that comes to mind would be is this SSI really needed or even benefiting the resident? Or would an adjustment in the long acting insulin (Lantus/Levemir) or mealtime insulin be more appropriate to proactively manage blood sugars? Another thought to consider is, with insulin being a high risk medication due to dangers related to severely low blood sugar (which could result in a fall or even potential hospitalization) that could potentially occur with a medication error, such as an incorrect dose given, does the risk outweigh the minimal benefit?

If you enjoyed this case on how to think clinically about medication management problems, you need to check out the free webinar on polypharmacy, packed with real life case scenarios –  Click Here to check it out!

Written By Eric Christianson

November 26, 2013

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