What is the recommended initial dose of fast-acting subcutaneous insulin (e.g. aspart (NovoLog), glulisine (Apidra), or lispro (Humalog)) for an insulin-naive patient presenting to the Emergency Department (ED) with hyperglycemia?

From the Guidelines

The recommended initial dose of fast-acting subcutaneous insulin (aspart, glulisine, or lispro) for an insulin-naive patient presenting to the ED with hyperglycemia is typically 0.1 units/kg body weight. For example, a 70 kg patient would receive approximately 7 units. This dose should be administered subcutaneously and can be repeated every 3-4 hours as needed based on blood glucose monitoring. When implementing this treatment, it's essential to check the patient's blood glucose before each dose and adjust accordingly. If the patient has severe hyperglycemia (>300 mg/dL), consider starting with 0.15 units/kg. Additionally, patients should be monitored for hypoglycemia, with glucose checks 1-2 hours after administration. Intravenous fluids may be necessary alongside insulin therapy, especially if the patient shows signs of dehydration. This dosing recommendation balances the need to lower blood glucose effectively while minimizing the risk of hypoglycemia in patients who have not previously received insulin therapy, as supported by the American Diabetes Association standards of medical care in diabetes 1.

Some key points to consider when administering fast-acting subcutaneous insulin in the ED setting include:

• Monitoring blood glucose levels closely to adjust the insulin dose as needed
• Being aware of the risk of hypoglycemia and taking steps to prevent it
• Considering the use of intravenous fluids to address dehydration
• Adjusting the insulin dose based on the patient's response to treatment
• Using a basal-plus-correction insulin regimen for patients with poor oral intake or those receiving nothing by mouth, as recommended by the American Diabetes Association 1.

It's also important to note that the sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, and a basal-bolus insulin regimen is preferred for patients with good nutritional intake 1.

Overall, the goal of insulin therapy in the ED setting is to safely and effectively lower blood glucose levels while minimizing the risk of hypoglycemia and other complications, as emphasized by the American Diabetes Association standards of medical care in diabetes 1.

From the Research

Recommended Fast-Acting Subcutaneous Insulin Dose

The recommended initial dose of fast-acting subcutaneous insulin for an insulin-naive patient presenting to the Emergency Department (ED) with hyperglycemia is not explicitly stated in the provided studies. However, the following points can be considered:

• The studies provide information on the pharmacokinetics and pharmacodynamics of fast-acting insulin analogues such as insulin glulisine 2, insulin aspart 3, and insulin lispro 4.
• The dose-proportionality of insulin glulisine has been established in patients with type 1 diabetes mellitus in the dose range of 0.075-0.15 U/kg, with a less than dose-proportional increase above 0.15 U/kg 2.
• In a study on patients with type 2 diabetes, the overall postprandial blood glucose excursions were lower with insulin glulisine than with insulin lispro 3.
• Insulin lispro has been shown to be effective in reducing post-prandial blood glucose levels in type 2 diabetic patients living in nursing homes 5.
• A comparison of preprandial insulin glulisine versus insulin lispro in people with type 2 diabetes over a 12-h period showed that glulisine achieves significantly lower glucose excursions than lispro 6.

Key Considerations

• The choice of fast-acting insulin analogue and the initial dose should be individualized based on the patient's specific needs and medical history.
• The patient's blood glucose level, insulin sensitivity, and other factors should be taken into account when determining the initial dose.
• It is essential to monitor the patient's blood glucose levels and adjust the insulin dose as needed to achieve optimal glycemic control.

Possible Dose Range

• Based on the available evidence, a possible initial dose range for fast-acting subcutaneous insulin in an insulin-naive patient with hyperglycemia could be 0.075-0.15 U/kg, as established in the study on insulin glulisine 2.
• However, this dose range may need to be adjusted based on the patient's individual response to insulin and their specific medical needs.