What is the protocol for moderate sliding scale pre-meal insulin (Regular Insulin) therapy?

From the Guidelines

A moderate sliding scale premeal insulin protocol should start with a dose of 4 U per meal, 0.1 U/kg per meal, or 10% of the basal insulin dose per meal, as recommended by the American Diabetes Association standards of medical care in diabetes 1.

Key Considerations

• The protocol should be adjusted based on individual patient factors, including weight, insulin sensitivity, and renal function.
• Patients with higher insulin resistance may need higher doses, while those with renal impairment or who are elderly may need lower doses.
• Blood glucose should be checked before each meal and at bedtime, with the corresponding insulin dose administered based on the reading.
• Rapid-acting insulin analogues are preferred due to their quick onset of action, and the dose should be decreased by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met.

Insulin Administration

• Insulin should be given 15-30 minutes before meals for regular insulin or 0-15 minutes before meals for rapid-acting analogs.
• The protocol should be used alongside a basal insulin regimen for optimal glycemic control.

Patient Factors

• Weight: patients with higher body weight may require higher doses of insulin.
• Insulin sensitivity: patients with lower insulin sensitivity may require higher doses of insulin.
• Renal function: patients with renal impairment may require lower doses of insulin due to the increased risk of hypoglycemia.

Monitoring and Adjustment

• Blood glucose levels should be monitored regularly to adjust the insulin dose as needed.
• The healthcare provider should be notified if the patient's blood glucose level exceeds 350 mg/dL, and the insulin dose should be adjusted accordingly.

Additional Options

• Premixed insulin products containing both basal and bolus insulin can be used for patients who may benefit from simpler dosing.
• Concentrated insulin preparations, such as U-500 regular insulin, can be used for patients requiring more than 200 units of insulin per day.

From the Research

Moderate Sliding Scale Premeal Insulin Protocol

• The concept of a moderate sliding scale premeal insulin protocol involves adjusting insulin doses based on premeal blood glucose levels to achieve optimal glycemic control 2, 3, 4.
• Studies have compared the efficacy of rapid-acting insulin analogues (RAIAs) and regular human insulin (RHI) in achieving glycemic control, with RAIAs showing better postprandial glucose control and less hypoglycemia in type 1 diabetes mellitus 2, 4.
• In type 2 diabetes, regular insulin may be a suitable choice for premeal insulin in lean patients, with comparable blood glucose levels to rapid-acting insulin 3.
• The choice of insulin type and dosage should be individualized based on patient characteristics, such as body mass index, and glucose control goals 3, 4.
• Insulin glulisine, a rapid-acting insulin analogue, has been shown to have comparable efficacy and safety to other RAIAs, such as lispro and aspart, in patients with type 1 diabetes 5, 6.

Key Considerations

• Glycemic control can be evaluated using measures such as glycated haemoglobin (HbA1c) level, pre- and postprandial glucose levels, and fasting plasma glucose level 4.
• The risk of complications, such as cardiovascular disease and eye problems, is increased by poor control of blood glucose levels and high blood glucose variability 4.
• Individualized insulin regimens, including moderate sliding scale premeal insulin protocols, can help achieve optimal glycemic control and reduce the risk of complications 2, 3, 4.