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November 19, 2001

Insulin

Question from Ridgecrest, California, USA:

In a previous question from someone else, a physician commented that he was not a big fan of using a sliding scale. Can he elaborate?

Answer:

In my view, sliding scales often have a place in diabetes management, but can be abused. Indeed, we use a variation of “sliding scales” when we give “correction boluses” to folks on insulin pumps. A sliding scale is used to bring down that aberrant high glucose reading.

However, what happens too often, especially in children with split doses of NPH and Regular and/or Humalog, is that care givers, trainers, and sometimes patients themselves will be giving numerous “extra” shots with their sliding scale to bring down a multitude of higher readings. If someone is giving extra shots very often, this indicates to me that the patient’s usual doses of insulin are inadequate. So instead of properly changing the baseline doses, they give these “chasing” insulin dosages. If one does not take into account the NPH given earlier in the day, for example, then the “extra” Regular given at lunch with the sliding scale can be “kicking in” during the soccer game, and then the patient has a severe low, which they treat with (often too much) glucose, causing the sugars to see-saw back up, which is treated with another shot from the sliding scale. And so on and so on. So chasing of glucose values can result in sporadic numbers, frustrating to everyone.

In addition, people don’t usually keep track of their sliding scale and note how often they give it or how much extra insulin they take. So, as a health care giver, I try to avoid the whole mess so as to try to prevent the higher sugars to begin with. So, sliding scales have a place, but not as a routine in my management.

DS