CME/CNE/CPE

Optimizing Insulin-Dependent Diabetes Management in Long-Term Care

Charles A. Cefalu, MD, MS

Louisiana State University
New Orleans, Louisiana

The questions below were submitted by your peers based on a recent CME/CNE/CPE activity.
The Course Director, Dr. Charles A. Cefalu, provides his answers below.

Question 1: How do you switch patients from sliding scale insulin to basal bolus insulin?

Question 2: Are there any situations where sliding scale insulin is preferable?

How do you switch patients from sliding scale insulin to basal bolus insulin?

Although sliding scale insulin (SSI) is widely used in hospitals and long-term care facilities, its routine and prolonged use is not recommended, as it lacks evidence and efficacy, results in greater patient discomfort and increased nursing time, and is associated with a greater risk of hypo- and hyperglycemia and resulting complications.

When blood glucose levels require correction using rapid-acting insulin, this can be done more accurately by calculating the patient’s insulin sensitivity (ie, the estimated reduction in plasma glucose per unit of insulin provided). Insulin sensitivity may be calculated on the basis of established formulas (eg, 1,500 divided by the patient’s average total daily insulin dose), and a patient-specific correction-dosing protocol may be ordered.

When long-acting insulin is used, a typical dose is 10 units per injection. Titrate the dose slowly upward by 2 units weekly until the desired fasting blood glucose levels are obtained. Treatment with insulin must be on an individualized basis.

For more information, see: Clinical Practice Guideline-Management of Diabetes in the LTC Setting. American Medical Directors Association. Columbia, MD; 2008.

Are there any situations where sliding scale insulin is preferable?

SSI protocols may be useful in newly recognized diabetes, during periods of hospitalization associated with acute stressful illness, or in the perioperative period when oral agents may be less acceptable or useful.

Any patient on SSI should be re-evaluated within 1 week and converted to fixed daily insulin doses that minimize the need for correction doses. It has been shown in long-term care facilities that blood glucose control can be achieved with single or multiple daily insulin injections, with few episodes of hypoglycemia.

For more information, see:

Clinical Practice Guideline-Management of Diabetes in the LTC Setting. American Medical Directors Association. Columbia, MD; 2008.
Halter JB. Diabetes Mellitus. In: Hazzard WR, Blass JP, Halter FB, Ouslander, JG, and Tinetti ME. Principles of Geriatric Medicine and Gerontology, 5th ed. The McGraw Hill Companies; New York; 2003:p. 868.