Intended for healthcare professionals

Rapid response to:

Practice Safety Alerts

Safer administration of insulin: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 341 doi: (Published 13 October 2010) Cite this as: BMJ 2010;341:c5269

Rapid Response:

A concession to physiological principles whilst awaiting evidence-based validation

The allusion to the multiplicity of sliding scale insulin (SSI)
regimes(1) bears testimony to the enduring popularity of SSI, not only for
diabetic patients who are temporarily prohibited from eating, but also, in
some cases, even for patients with diabetic ketoacidosis(2). The
alternative, at least for diabetic patients who are temporarily prohibited
from eating, is to prescrbe insulin prospectively (so-called prospective
regime) on the assumption that all diabetic patients have a basal insulin
requirement defined as "the amount of exogenous insulin per unit of time
necessary to prevent unchesked gluconeogenesis and ketogenesis"(3).

Incorporated into the computation of the basal insulin requirement are
variables such as body/mass index (BMI)(3), HbA1c(4), and whether or not
the patient has type 1 diabetes(5). Due allowance also has to be made for
"an increase in insulin requirement that generally accompanies acute
illness"(3). Computations of the SSI dose, on the other hand, are much
simpler, being based pricipally, if not solely, on the instantaneous blood
glucose level, without making any concession to complex physiological
principles. In the absence of an evidence base favouring either the
prospective regime or the SSI the major question facing clinicians is
whether to base clinical practice on physiological principles, however
complex, or to rely soley on hunch, instinct, and experience, as appears
to be the case with the SSI.


(1) Ahmed M., Tiew S
Sliding scales just as slippery: we need local real-time learning
BMJ rapid response 25/10/2010

(2)Devalia B
Adherence to protocol during acute management of diabetic ketoacidosis:
would specialist involvement lead to better outcomes?
The International Journal of Clinical Practice 2010;64:1580-1582

(3)Clement S., Braithwaite SS., Ahmann A et al
Management of diabetes and hyperglycemia in hospitals
Diabetes Care 2004;27:553-591

(4)Donaldson S., Villanuueva G., Rondinelli L., Baldwin D
Rush University guidelines and protocols for the management of
hyperglycemia in hospitalized patients
Elimination of the sliding scale and improvement of glycemic control
throughout the hospital
The Diabetes Educator 2006;32:954-962

(5)Tridgell DM., Tridgell AH., Hirsch IB
Inpatient management of adults and children with type 1 diabetes
Endoscrinology and Metabolism Clinics of North America 2010;39:595-608

Competing interests: No competing interests

29 October 2010
oscar,m jolobe
retired geriatrician
manchester medical society