What is the protocol for determining insulin sliding scale usage prior to meals for patients with hyperglycemia?

From the Guidelines

The protocol for determining insulin sliding scale usage prior to meals for patients with hyperglycemia involves measuring the patient's blood glucose level before each meal and at bedtime, then administering a predetermined dose of rapid-acting insulin based on those readings, with a recommended scale of 2 units for premeal glucose >250 mg/dL and 4 units for premeal glucose >350 mg/dL, as suggested by the most recent guidelines 1.

Key Considerations

• The specific scale should be individualized based on the patient's insulin sensitivity, weight, overall health status, and previous response to insulin.
• Healthcare providers should also consider the patient's meal content, planned physical activity, and concurrent medications when determining appropriate dosing.
• Regular monitoring and adjustment of the sliding scale are essential, as insulin requirements may change over time.

Evidence-Based Recommendations

• The American Diabetes Association recommends using a basal-bolus insulin regimen, which includes a basal insulin dose and a preprandial dose, rather than a sliding-scale insulin regimen alone 1.
• The 2024 guidelines suggest using a simplified sliding scale, with 2 units of short- or rapid-acting insulin for premeal glucose >250 mg/dL and 4 units for premeal glucose >350 mg/dL 1.
• The guidelines also recommend adjusting insulin dose and/or adding glucose-lowering agents based on fingerstick glucose testing performed before lunch and before dinner, with a goal of 90–150 mg/dL before meals 1.

Important Notes

• Sliding-scale insulin regimens should be used with caution, as they may not provide optimal glycemic control and can increase the risk of hypoglycemia.
• Basal insulin coverage is essential for optimal glycemic control and should be used in conjunction with sliding-scale insulin, if necessary.
• Regular monitoring and adjustment of the sliding scale are crucial to ensure that the patient's insulin requirements are met and to minimize the risk of hypoglycemia or hyperglycemia.

From the FDA Drug Label

Insulin aspart was administered by subcutaneous injection immediately prior to meals and regular human insulin was administered by subcutaneous injection 30 minutes before meals.

The protocol for determining insulin sliding scale usage prior to meals for patients with hyperglycemia is not explicitly stated in the provided drug label. However, it can be inferred that insulin aspart can be administered immediately prior to meals.

• The label does not provide a specific sliding scale protocol.
• It does mention that insulin aspart was administered by subcutaneous injection immediately prior to meals in clinical studies.
• The studies compared the safety and efficacy of insulin aspart to regular human insulin in patients with type 1 and type 2 diabetes 2.

From the Research

Determining Insulin Sliding Scale Usage

To determine insulin sliding scale usage prior to meals for patients with hyperglycemia, several factors must be considered, including the type of insulin, the patient's meal schedule, and their individual glucose levels.

• The type of insulin used can affect the timing of administration, with rapid-acting insulins like insulin lispro 3 and insulin aspart 4 typically administered immediately before meals, while intermediate-acting insulins like NPH insulin 5 may be given every 4 or 6 hours.
• The patient's meal schedule is also important, as insulin administration should be coordinated with meal times to minimize the risk of hypoglycemia and optimize glucose control 3, 4.
• Individual glucose levels should be monitored and used to adjust the insulin dose, with the goal of maintaining blood glucose levels within a target range 3, 4, 5.

Insulin Administration Timing

The timing of insulin administration can vary depending on the type of insulin and the patient's schedule.

• Insulin glargine, a long-acting insulin, can be administered at bedtime, before breakfast, or before dinner, with similar efficacy 6.
• Insulin lispro and insulin aspart, rapid-acting insulins, are typically administered immediately before meals 3, 4.
• NPH insulin, an intermediate-acting insulin, may be given every 4 or 6 hours, with better glucose control observed when administered every 4 hours 5.

Glucose Monitoring and Dose Adjustment

Regular glucose monitoring is essential to adjust the insulin dose and maintain optimal glucose control.

• Blood glucose levels should be monitored at regular intervals, including before meals and at bedtime 3, 4, 5.
• The insulin dose should be adjusted based on glucose levels, with the goal of maintaining blood glucose levels within a target range 3, 4, 5.
• The use of a sliding scale insulin regimen, where the insulin dose is adjusted based on glucose levels, can be an effective strategy for managing hyperglycemia in patients with continuously tube-fed patients 5.