Updating the beers criteria
In 2012, the American Geriatrics Society increased its focus on sliding-scale insulin by updating the Beers criteria for potentially inappropriate medication use in the elderly to avoid its use due to a higher risk of patients experiencing hypoglycemia without an improvement in the management of hyperglycemia, regardless of setting.7 The Sliding-Scale Roller Coaster Sliding-scale insulin often fails to individualize insulin requirements and bases insulin doses on glucose levels prior to meals without regard to a patient’s basal metabolic needs, the types and amounts of food to be consumed, a patient’s weight, or other factors influencing insulin demands such as previous insulin needs, insulin sensitivity, or resistance.8 For example, a patient weighing 80 kg would receive the same insulin dose as a patient weighing 65 kg if their blood glucose levels are within the same range.Subsequently, the 80-kg patient may not receive sufficient insulin, placing him or her at increased hyperglycemia risk, and the 65-kg patient may receive a potentially excessive dose that could result in hypoglycemia.It’s recommended that basal insulin be given routinely to account for patients’ basal metabolic insulin requirements and prevent the liver from overproducing glucose, which leads to hyperglycemic episodes. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.The use of long-acting basal insulin has been shown to provide glycemic control superior to sliding-scale insulin with less hypoglycemic risk.11 Nutritional or bolus insulin is recommended to cover insulin needs to convert mealtime glucose into energy without postprandial hyperglycemia. This “roller coaster” effect of fluctuating glucose levels repeats itself with evidence existing now that these fluctuations are more harmful physiologically than blood glucose levels that are continuously elevated, even when the elevation is considered mild.10 Pushing for Structured Insulin Regimens Best practice guidelines now recommend the use of structured insulin regimens with three components: basal insulin, nutritional insulin, and correctional insulin.Regimens combining these components have been shown to reduce fluctuations in blood glucose levels, increase the number of days patients maintain acceptable blood glucose levels, and reduce the length of non-ICU stays for hospitalized patients. Patients with diabetes typically have medical expenses that are 2.3 times higher than those of nondiabetics,1 and families with a child who has diabetes reportedly spend as much as 10% of their income on the disease.2 Beyond the financial cost, diabetes can have a tremendous negative impact on patients and their families due to associated intangibles that are more difficult to measure, such as pain, depression, anxiety, inconvenience, and a lower quality of life. The overall costs related to diabetes treatment place a tremendous burden on the healthcare system, with one in five US healthcare dollars being spent on the condition.
Additionally, patients on these regimens experienced blood glucose levels greater than 300 mg/d L at a rate three times that of patients on other insulin regimens that were more intensive and physiological based.4 Clinicians’ failure to adjust sliding-scale insulin to improve glycemic control once these regimens have been implemented is an issue in both hospitals and nursing homes.Dosages are individualized using a correction factor (also called a sensitivity factor), which represents the degree to which 1 unit of rapid-acting insulin lowers a patient’s blood glucose level. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Correction doses of insulin are based on preprandial blood glucose levels. The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus. Inadequate blood glucose control over an extended period of time can result in significant long-term complications affecting multiple organ systems with reduced quality of life and increased mortality and morbidity (see Table 1 below).Short-term complications related to the failure to control glycemic levels can result in symptoms associated with periods of hyperglycemia.Weight-based formulas are essential for helping to control hyperglycemia by preventing underdosing and reducing hypoglycemic risks related to overdosing when patient weight is not considered. Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy. Other considerations also are taken into account, such as a patient with a muscular frame who may require less insulin than an obese patient with the same weight. Evaluation of hospital glycemic control at US academic medical centers. Within a few hours, his or her glucose level increases, leaving him or her with long periods of high blood glucose levels.Insulin is then administered with the next glucose check, and blood glucose returns to normal.Eighty-three percent of the residents started on sliding-scale insulin remained on the regimen at the end of the study.Of those patients not started on it, 33% were later switched from other diabetic regimens to sliding-scale insulin.6 The widespread use of sliding-scale insulin in nursing homes remains persistent despite recommendations from the American Medical Directors Association to avoid the practice.