What type of insulin can I start for a sliding scale regimen?

Rapid-Acting Insulin Analogs Are Preferred for Sliding Scale Insulin Regimens

For sliding scale insulin regimens, rapid-acting insulin analogs such as insulin aspart, lispro, or glulisine are the preferred options due to their quick onset of action and shorter duration, which better addresses post-meal hyperglycemia with lower risk of delayed hypoglycemia. 1

Sliding Scale Insulin Options

Preferred Options:

• Rapid-acting insulin analogs:
  • Insulin aspart (Novolog, Fiasp)
  • Insulin lispro (Humalog)
  • Insulin glulisine (Apidra)

These insulins have:

• Onset of action: 10-15 minutes
• Peak effect: 1-2 hours
• Duration: 3-4 hours

Alternative Option:

• Regular (short-acting) insulin:
  • Human regular insulin (Humulin R, Novolin R)
  • Onset: 30-60 minutes
  • Peak: 2-3 hours
  • Duration: 5-8 hours

Implementation Guidelines

When implementing a sliding scale insulin regimen:

1. Start with a standardized protocol:

   • Use a preprinted physician order form when available
   • Select appropriate scale based on insulin sensitivity
   • Example basic scale:
     • Blood glucose >150-200 mg/dL: 2 units
     • Blood glucose >200-250 mg/dL: 4 units
     • Blood glucose >250-300 mg/dL: 6 units
     • Blood glucose >300-350 mg/dL: 8 units
     • Blood glucose >350 mg/dL: 10 units and notify provider

2. Timing considerations:

   • Administer before meals and at bedtime for patients who are eating
   • For NPO patients or continuous tube feeding, administer every 4-6 hours

3. Documentation:

   • Record blood glucose results and insulin doses administered
   • Monitor for patterns requiring adjustment

Important Considerations and Pitfalls

Limitations of Sliding Scale Insulin:

• Sliding scale insulin alone is reactive rather than preventive and has been associated with suboptimal glycemic control 1, 2, 3
• Meta-analyses show that sliding scale insulin as monotherapy may increase hyperglycemic events 3

Avoid These Common Errors:

• Using sliding scale insulin as the sole therapy for patients with established insulin requirements
• Failing to adjust the sliding scale based on patterns of hyper/hypoglycemia
• Not considering the patient's nutritional status when selecting insulin type

Best Practices:

• Combine sliding scale insulin with basal insulin for better glycemic control
• For patients on continuous tube feeding, consider NPH insulin every 4-6 hours instead of rapid-acting insulin 4
• Regularly evaluate the effectiveness of the sliding scale and adjust as needed

Special Situations

• Continuous enteral nutrition: NPH insulin every 4-6 hours may provide better glycemic control than rapid-acting insulin analogs 4
• Critically ill patients: Consider IV regular insulin infusion rather than subcutaneous sliding scale 1
• Older adults: May need lower doses and higher glycemic targets to avoid hypoglycemia 1

Remember that while sliding scale insulin can help manage acute hyperglycemia, it should ideally be part of a comprehensive insulin regimen that includes basal insulin coverage for most hospitalized patients with diabetes.