Sliding-Scale Insulin: Time to Say Goodbye?

A recent retrospective analysis showed that nearly 75% of long-term care patients with diabetes received SSI.

Controlling diabetes in long-term care senior patients is not an easy task. Polypharmacy, kidney disease, and irregular meals make oral antidiabetic mediations a less-than-ideal option. For this reason, long-term care facilities often use sliding-scale insulin (SSI). A recent retrospective analysis showed that nearly 75% of long-term care patients with diabetes received SSI.

An article published in the February 2017 issue of The Consultant Pharmacist reviewed SSI use in long-term care, highlighted its drawbacks, and explored alternatives.

SSI regimens involve finger-stick blood glucose testing followed by short-acting insulin administration. The insulin dose is variable based on the blood glucose reading.

However, SSI therapy use has risks, and the American Diabetes Association (ADA) currently recommends against SSI use. Aside from frequent finger sticks, SSI has shown poorer glucose control and a higher burden of care.

The Centers for Medicare and Medicaid Services (CMS) created an assessment tool to evaluate adverse event risk in nursing facility practices. The tool specifically identifies SSI use as a risk factor for hypoglycemia. The CMS recommends strict documentation of insulin administration and monitoring of signs/symptoms and food consumption as prevention techniques.

The American Medical Directors Association (AMDA) also published recent guidelines that advise against routine use of SSI. The authors recommend using this information to educate staff and create regulated diabetes care protocols for safe insulin use.

Basal-bolus insulin (B-BI) is mentioned as an alternative option to SSI. With B-BI therapy, patients receive a long-acting basal insulin for 24-hour coverage along with bolus rapid-acting insulin before meals. B-BI mimics physiological insulin release and has been shown to significantly decrease fasting blood glucose levels compared to SSI.

SSI therapy is commonly used in long-term care facilities despite strong counter-evidence from the ADA, AMDA, CMS, and other diabetes care experts. Providers at these facilities must consider the evidence and adjust current guidelines to meet their patient’s needs.

Reference

Bear MD, Bartlett D, Evans P. Pharmacist counseling and the use of nonsteroidal anti-inflammatory drugs by older adults. Consult Pharm. 2017;32(3):161-168.