Alternatives to sliding scale insulin therapy, recommended by doctors

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This article was medically reviewed by Jason R. McKnight, MD, MS, a family medicine physician and clinical assistant professor at Texas A&M College of Medicine.

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• Sliding scale insulin therapy uses your pre-meal blood sugar level to determine insulin dosage.
• Research indicates sliding scale insulin therapy is ineffective at managing blood sugar levels.
• Therefore, try an alternative method like insulin pumps or once-weekly injections.

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Of the more than 30 million Americans with diabetes, about 7.4 million use one or more forms of supplemental insulin to help keep their blood sugar levels within a certain target range.

Insulin therapy is an important part of treatment for people living with diabetes. Sliding scale insulin (SSI), once a prominent diabetes treatment, entails checking your blood sugar levels before meals. Your pre-meal blood sugar then determines your insulin dosage.

While sliding scale insulin therapy is still used today in the hospital setting, the approach has become increasingly controversial as more research has revealed that it can fail to improve blood sugar control.

Using the right amount of insulin is crucial because too little causes persistently high blood sugar, which can damage the heart, eyes, kidneys, nerves, and blood vessels, says Patricia Peter, MD, Yale Medicine endocrinologist. Meanwhile too much causes low blood sugar, which leads to hunger, irritability, seizures, and even comas.

Important: According to the American Diabetes Association, prolonged use of sliding scale insulin as the sole method for regulating blood sugar levels was found to be ineffective in the majority of patients.

How sliding scale insulin therapy works

SSI therapy requires checking your blood glucose levels about four times a day before each meal. The higher your blood sugar, the more insulin you'll likely need to take to get your blood sugar levels back to a normal range, hence the name "sliding scale."

A sliding-scale insulin regimen typically involves these steps:

1. Check blood glucose levels with a glucometer 15 minutes before a meal and 15 minutes before bedtime.
2. If your glucose is elevated above 150 mg/dL, you'll take a certain number of insulin units on the sliding scale you were prescribed by your doctor. Typically, this will mean taking 1 to 3 units of insulin for every 50 mg/dL above 150 on your glucometer reading, says Serena Cardillo, MD, an endocrinologist and diabetes specialist at Penn Medicine.
3. Even if your pre-meal blood glucose is within a normal range, aka less than 140 mg/dL, you may still need to administer a dose of rapid-acting insulin, according to Cardillo. Rapid-acting insulin begins working within 15 minutes and lasts for two to four hours. This could be a specific prescribed dose, such as taking 5 units with each meal, or a flexible dose based on the number of carbohydrates you'll be eating, such as 1 unit per every 15 grams of carbs.

Important: If using SSI therapy, consume about the same amount of carbohydrates at each meal, and eat your meals at a consistent time each day. That's because carbs have a significant impact on your blood sugar and varying the amount you eat could make your SSI chart less accurate.

Here's a sample chart for sliding-scale insulin, per the University Medical Center pharmacy:

Blood glucose (mg/dL)

Low dose: For highly insulin-sensitive patients

Moderate dose: For patients with normal insulin sensitivity

High dose: For highly insulin-resistant patients

Less than 70

Follow HYPOglycemia Guidelines

Follow HYPOglycemia Guidelines

Follow HYPOglycemia Guidelines

70-139