Montefiore Einstein Department of Medicine

Sliding-Scale vs. Basal-Bolus Insulin Therapies in Older Adults

T.S. Dharmarajan research study nursing home insulin therapy SSI B-BI Albert Einstein College of Medicine Montefiore Medical Center Bronx NY

Type 2 diabetes is common among nursing home residents and often treated with sliding-scale insulin (SSI) therapy, despite current recommendations that do not support this method. A recent study by Dr. T.S.Dharmarajan and colleagues compared the effectiveness of SSI therapy to basal-bolus insulin (B-BI) therapy to control blood glucose in older nursing home residents with type 2 diabetes.

SSI therapy and B-BI therapy share the same medication—insulin—but differ in the timing of administration in relation to meals, dosage, and type(s) of insulin given to patients with type 2 diabetes. SSI regimens administer insulin after demonstrated elevations in blood glucose, a reactive strategy that is not physiological. B-BI therapy takes a more personalized approach, using both a longer acting form of insulin to provide steady regulation of blood sugar (even between meals) and separate injections of shorter-acting insulin throughout the day along with meals. B-BI therapy roughly simulates a non-diabetic body’s delivery of insulin. The B-BI approach is more physiological and mimics pancreatic release of insulin to provide a steady-state regulation, essentially a proactive approach.

T.S. Dharmarajan Geriatrics Department of Medicine Albert Einstein College of Medicine Montefiore Medical Center Bronx NY
T.S. Dharmajan, MD, MBBS

Dr. Dharmarajan's study, sponsored by the AMDA Foundation and scheduled to appear in the March 2016 print issue of the Journal of the American Medical Directors Association (published online in September 2015), measured levels of fasting blood glucose (FBG) in 64 nursing home residents from 14 long-term care sites randomly assigned to SSI or B-BI therapies over a 21-day clinical intervention trial. Participants treated with B-BI had significantly lower 3-day average FBG levels compared to the SSI participants. The study concluded that switching long-term care patients with type 2 diabetes to B-BI therapy is feasible, safe, and effective.

"As physicians who care for patients with diabetes, our primary goal is to achieve a level of glycemic control that mimics that of nondiabetic patients, and B-BI therapy appears to be a more effective way to do that," Dr. Dharmarajan said. "It is time for us to shift from a reactive to a physiologically proactive approach."

Dr. Dharmarajan is Vice Chairman of the Department of Medicine, Clinical Director of the Division of Geriatrics, and Program Director of the Geriatric Medicine Fellowship Program at Montefiore Medical Center (Wakefield Campus). He was instrumental in developing the Wakefield Campus's large inpatient geriatric medicine program, with recognized clinical, academic and research components, including a fully accredited geriatrics fellowship program. His research interests focus primarily in the areas of geriatrics, nutrition, anemia and anticoagulation. A prominent local, national and international speaker and recipient of numerous teaching and mentoring awards, he has been featured on the cover of AgingWell magazine as one of the country's noteworthy geriatricians.

Published February 21, 2016 

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