Standard Novorapid (Insulin Aspart) Sliding Scale Protocol
The standard Novorapid sliding scale for hospitalized patients is a simplified protocol where 2 units are given for blood glucose >250 mg/dL (13.9 mmol/L) and 4 units for blood glucose >350 mg/dL (19.4 mmol/L), administered before meals. 1
Recommended Sliding Scale Framework
Basic Sliding Scale Structure
- Pre-meal blood glucose monitoring (before breakfast, lunch, and dinner)
- Rapid-acting insulin (Novorapid/insulin aspart) administered based on blood glucose readings
- Do not administer rapid-acting insulin at bedtime to avoid nocturnal hypoglycemia 1
Standard Dosing Protocol
| Blood Glucose Level | Novorapid (Insulin Aspart) Dose |
|---|---|
| <90 mg/dL (<5.0 mmol/L) | No insulin |
| 90-150 mg/dL (5.0-8.3 mmol/L) | No insulin (target range) |
| 151-250 mg/dL (8.4-13.8 mmol/L) | Consider 1-2 units* |
| >250 mg/dL (>13.9 mmol/L) | 2 units |
| >350 mg/dL (>19.4 mmol/L) | 4 units |
*Dose may vary based on institutional protocol
Important Considerations
Limitations of Sliding Scale Alone
Sliding scale insulin (SSI) alone is associated with suboptimal glycemic control and increased risk of hyperglycemic episodes compared to basal-bolus regimens 2. Research shows that when used without a standing dose of intermediate-acting insulin, sliding scales are associated with a 3-fold higher risk of hyperglycemic episodes 2.
Recommended Approach
- Combine with basal insulin - For optimal glycemic control, sliding scale insulin should be used in conjunction with basal insulin rather than as monotherapy 1
- Monitor frequently - Check blood glucose before meals and at bedtime
- Adjust as needed - If 50% of pre-meal glucose values over 2 weeks are above target, increase the dose or add another agent 1
- Avoid hypoglycemia - If >2 pre-meal glucose values/week are <80 mg/dL (4.4 mmol/L), decrease the dose by 2 units 1
Special Situations
Continuous Enteral Feeding
For patients on continuous enteral feeding, consider:
- Regular insulin every 6 hours or rapid-acting insulin every 4 hours
- Starting with 1 unit per 10-15g of carbohydrate
- Adjust daily based on response 1
Perioperative Management
- Monitor blood glucose every 4-6 hours while NPO
- Dose with short-acting insulin as needed
- Target range: 80-180 mg/dL (4.4-10.0 mmol/L) 1
Common Pitfalls to Avoid
- Using sliding scale as sole therapy - This leads to poor glycemic control; always consider adding basal insulin 1
- Administering rapid-acting insulin at bedtime - Increases risk of nocturnal hypoglycemia 1
- Failing to adjust the scale - Sliding scales should be adjusted based on individual response 1
- Not considering patient-specific factors - Factors like renal function, steroid use, and nutritional status affect insulin requirements 1
- Continuing sliding scale indefinitely - Stop sliding scale when no longer needed daily 1
Remember that standardized insulin protocols have been shown to reduce medication errors and adverse events related to sliding scale insulin 3. The goal is to maintain blood glucose between 90-150 mg/dL (5.0-8.3 mmol/L) before meals while minimizing hypoglycemic episodes.