Updating the beers criteria

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.

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.

Rapid-acting insulin is used to cover nutritional intake and correct hyperglycemia.

Basal plus rapid-acting insulin (often called basal/bolus insulin therapy) most closely mimics normal physiologic insulin production and controls blood glucose more effectively. Glycaemic variability and complications in patients with diabetes mellitus: evidence from a systematic review of the literature.

The risk of hypoglycemia is of significant concern since administering insulin doses without regard to meal intake and other factors can result in excessive doses of insulin being administered.5 Another common sliding-scale insulin scenario occurs when a patient does not receive insulin when his or her glucose level is normal.

Barriers to Changing the Culture Barriers to changing the sliding-scale insulin culture to one that embraces newer physiological insulin regimens include practitioners’ resistance to change, fear of hyperglycemia overcorrection and possible hypoglycemia, poor blood glucose monitoring, failure to obtain a patient’s weight, reluctance to spend time calculating nutritional and correctional doses, fear of calculation errors, and lack of understanding of the risk associated with sliding-scale insulin.12 Overcoming these barriers requires buy-in from the entire healthcare team and requires the ongoing education of administrators, prescribers, nurses, dietitians, and pharmacists.

A multidisciplinary effort is necessary to push back against the continued use of sliding-scale insulin, and the healthcare team must design and implement adequate policies to promote the use of these newer insulin regimens.

A retrospective observational study conducted at a large medical center observed 84% of patients on sliding-scale insulin experienced hyperglycemia, with dosage adjustments occurring in only 18% of these patients.5 A longitudinal study reviewed 9,804 diabetic patients aged 65 and older who had resided in a nursing home for at least one month.

Fifty-four percent of the patients were started on sliding-scale insulin during their stay, and 22% of all insulin orders in the facilities involved a sliding-scale regimen.

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