1099-P: Sliding Scale Insulin Use in Noncritical Care Settings: Who Can Slide?

Despite recommendations of clinical guidelines, sliding scale insulin (SSI) is widely used for the inpatient management of patients with T2D. To understand if there is a population of patients for whom SSI may be an appropriate form of management, we utilized a large database from a single academic institution to define the frequency of SSI usage and determine factors that predict adequate glycemic control with SSI alone in the non-critical care setting. Among 15,348 patients with T2D (28% surgery, 72% medicine), 7,052 (45%) were managed with SSI and 8,296 (55%) with basal insulin. Average admission blood glucose (BG) and HbA1c were lower in patients treated with SSI (154.6±60.3 vs. 191.7±80.8 mg/dl, p<0.001; 7.0±1.5 vs. 8.5±2.1%, p<0.001). Charlson comorbidity score was higher in those treated with basal compared to SSI. Surgical patients were more likely to be treated with SSI than those on medicine services (53% vs. 43%, p<0.001). Hypoglycemia rates were lower with SSI vs. basal insulin (6.9% vs. 14%, p<0.001). Seventy-two percent of patients treated with SSI had an admission BG <180 mg/dl; of them, 93% maintained good glycemic control (mean hospital BG <180 mg/dl). After adjusting for age, gender, BMI, race, Charlson score, and setting (med vs. surg), patients treated with SSI admitted with BG <180 mg/dl had much higher odds of achieving good glycemic control compared to those admitted with BG 180-280 [OR 6.4 (95% CI 5.6, 7.3)] or >280 mg/dl [OR 42.2 (29.5, 60.5)]. Similar results were seen when comparing patients with admission A1c <7% to A1c 7-9% [OR 2.4 (1.9, 2.9)] or A1c >9% [OR 13.3 (8.8, 19.9)].

Conclusion: SSI is used in ~40% of non-critically ill patients, especially among those with mild/moderate hyperglycemia. Most patients with BG <180 mg/dl and A1c <7% treated with SSI maintain good glycemic control (mean hospital BG <180 mg/dl) while hospitalized, suggesting that basal insulin may not be necessary. Further RCT are needed to identify a subpopulation for whom SSI may be appropriate in the hospital.