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Sliding scale from harrison book

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I now have all the relevant content from Harrison's. Here is a full summary of what Harrison's 22nd Edition says about the sliding scale:

Sliding Scale Insulin - Harrison's Principles of Internal Medicine, 22e (2025)

What is the Sliding Scale?

The "sliding scale" refers to giving short-acting or rapid-acting insulin alone, where no insulin is given unless the blood glucose is elevated - and the dose "slides" upward as the glucose rises. It is a reactive, not a proactive, approach.

Harrison's Position: Sliding Scale is INADEQUATE

"Sliding scale, with short-acting or rapid-acting insulin alone, where no insulin is given unless the blood glucose is elevated, is inadequate for inpatient glucose management."
  • Harrison's 22e, Chapter on Management of Diabetes in a Hospital Setting
Why it fails:
  • It does not provide basal insulin coverage
  • It only reacts after hyperglycemia has already occurred
  • It does not account for meal-related glucose excursions
  • It leads to unpredictable and inadequate glucose control

What Harrison's Recommends Instead: Basal-Bolus Regimen

For non-ICU / non-critically ill patients, the preferred approach is:
ComponentDetails
Basal insulinSC long-acting insulin (e.g., glargine, detemir)
Prandial insulinRapid-acting insulin before meals (e.g., lispro, aspart) - based on anticipated carbohydrate intake
Corrective ("sliding") insulinAdded on top of the prandial dose, based on insulin sensitivity and current glucose

Corrective Insulin - The Right Way to Use a "Scale"

When used as a corrective dose added to basal/bolus insulin (not as a standalone), Harrison's gives these examples:
  • Insulin-sensitive patient (thin): 1 unit for every 2.7 mmol/L (50 mg/dL) above the glucose target
  • Insulin-resistant patient (obese): 2 units for every 2.7 mmol/L (50 mg/dL) above the glucose target
The key principle: individualize the regimen and adjust basal and prandial doses frequently based on how much corrective insulin was needed.

Glycemic Targets in Hospitalized Patients (ADA, per Harrison's)

SettingTarget Glucose
Critically ill / non-critically ill7.8-10.0 mmol/L (140-180 mg/dL)
Selected patients (tighter control)6.1-7.8 mmol/L (110-140 mg/dL) - avoid hypoglycemia
Perioperative period4.4-10.0 mmol/L (80-180 mg/dL)
Note: Strict glycemic control in acutely ill patients worsens outcomes and increases hypoglycemia risk. Very intensive control is not recommended.

Perioperative Setting

  • Perioperative hyperglycemia: treat with IV short-acting insulin infusion OR subcutaneous sliding-scale insulin
  • Oral hypoglycemic agents should NOT be given on the morning of surgery
  • SGLT-2 inhibitors should be stopped up to 1 week before planned admission (risk of euglycemic DKA)

In Older Adults / Long-Term Care (Harrison's Chapter on Diabetes in Older Adults)

"Avoid sliding scale in post-acute care settings" - it is associated with relatively high incidence of hypoglycemia, challenges of repeated glucose measurements, and high burden on caregivers.
Basal insulin injection therapy is preferred in older patients as it has minimal side effects.
Bottom line from Harrison's: The sliding scale as a standalone regimen is discouraged. It should only be used as a corrective component added on top of a structured basal-bolus regimen, individualized to the patient's insulin sensitivity.
  • Harrison's Principles of Internal Medicine 22e, Chapter 416: Management of Diabetes in a Hospital or Facility

Create a quick reference PDF comparing sliding scale vs basal-bolus insulin

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ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace not found"

Running Command

mkdir -p /home/daytona/workspace/insulin-pdf && python3 -c "import reportlab; pr…

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~/insulin-pdf/build_pdf.py

build_pdf.pyPython
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