Death to the Sliding Scale!

The practice of sliding-scale insulin management persists even though it has been called “a relic from the past” that “should be left in the medical history books.”1 It remains a common practice in many health care settings. And, in my opinion, it is a prime example of a diabetes treatment strategy that makes no sense but that many providers continue to employ without regard for common sense or science.Some would say that the argument surrounding the practice of sliding-scale insulin administration is merely a matter of semantics and that, in today’s world of basal-bolus insulin regimens, “sliding scales,” “correction boluses,” “algorithms,” and “supplemental insulin” are really just the same thing. I would contend that, in some cases, correction boluses, algorithms, and supplements are actually sliding scales in disguise and, as such, are problematic.Still, this editorial will focus on the old concept of a sliding scale—a concept that is still alive and well throughout the United States. It is still used by many physicians, and it is still taught to many of our health care students and medical residents. Sliding scales are not found in students’ textbooks, but they are still learned through observation and practice.My impetus for writing this editorial came from a recent personal experience that left me frustrated and angry—frustrated over how my own father-in-law’s diabetes was being managed in a hospital setting, and angry because I could not protect him from the effects of an outdated insulin management strategy that remains pervasive despite numerous studies illustrating its shortcomings and editorials calling for its demise.2–5Over the past several years, my father-in-law has been hospitalized repeatedly for treatment of complications related …