What is the recommended Humalog (insulin lispro) sliding scale protocol for managing hyperglycemia?

Humalog (Insulin Lispro) Sliding Scale Protocol for Managing Hyperglycemia

A basal-bolus insulin regimen that includes Humalog (insulin lispro) as the rapid-acting component is strongly recommended over using sliding scale insulin alone for managing hyperglycemia in hospitalized patients. 1

Recommended Insulin Regimen Approach

For Non-Critically Ill Hospitalized Patients:

1. Basal-Bolus Regimen (Preferred):

   • Total daily insulin dose: 0.3-0.5 units/kg for insulin-naive patients 1
   • Distribution:
     • 50% as basal insulin (once or twice daily)
     • 50% as prandial Humalog (divided into three doses before meals)
     • Plus correction doses of Humalog for hyperglycemia

2. Dose Adjustments for Special Populations:

   • For patients at higher risk of hypoglycemia (elderly >65 years, renal failure, poor oral intake): Use lower doses 1
   • For patients on higher insulin doses at home (≥0.6 units/kg/day): Reduce total daily dose by 20% while hospitalized 1

3. For Patients with Poor Oral Intake or NPO Status:

   • Use basal insulin plus correction doses of Humalog 1
   • Consider basal-plus approach (0.1-0.25 units/kg/day of basal insulin with correction doses) 1

Sample Humalog Correction Scale

Mild Hyperglycemia Correction Scale:

• BG 150-200 mg/dL: 2 units Humalog
• BG 201-250 mg/dL: 4 units Humalog
• BG 251-300 mg/dL: 6 units Humalog
• BG 301-350 mg/dL: 8 units Humalog
• BG 351-400 mg/dL: 10 units Humalog
• BG >400 mg/dL: 12 units Humalog and notify physician

Moderate Hyperglycemia Correction Scale:

• BG 150-200 mg/dL: 4 units Humalog
• BG 201-250 mg/dL: 6 units Humalog
• BG 251-300 mg/dL: 8 units Humalog
• BG 301-350 mg/dL: 10 units Humalog
• BG 351-400 mg/dL: 12 units Humalog
• BG >400 mg/dL: 14 units Humalog and notify physician

Severe Hyperglycemia Correction Scale:

• BG 150-200 mg/dL: 6 units Humalog
• BG 201-250 mg/dL: 8 units Humalog
• BG 251-300 mg/dL: 10 units Humalog
• BG 301-350 mg/dL: 12 units Humalog
• BG 351-400 mg/dL: 14 units Humalog
• BG >400 mg/dL: 16 units Humalog and notify physician

Monitoring Protocol

• For patients who are eating: Check blood glucose before meals 1
• For patients not eating: Check blood glucose every 4-6 hours 1
• For patients on IV insulin: Check blood glucose every 30 minutes to 2 hours 1
• Adjust insulin doses based on patterns of glycemic control

Important Considerations and Pitfalls

1. Avoid Sliding Scale Insulin Alone:

   • Using only sliding scale insulin is strongly discouraged 1
   • Associated with clinically significant hyperglycemia 1
   • Treats hyperglycemia after it has occurred rather than preventing it 1
   • Exception: May be appropriate for patients without diabetes who have mild stress hyperglycemia 1

2. Hypoglycemia Risk Management:

   • Basal-bolus regimens have 4-6 times higher risk of hypoglycemia compared to sliding scale alone 1
   • Monitor for blood glucose <70 mg/dL (moderate hypoglycemia) or <54 mg/dL (severe hypoglycemia) 1
   • Treat hypoglycemia promptly with oral carbohydrates or IV glucose if NPO 1
   • Review and modify regimen after hypoglycemic episodes 1

3. Critical Care Considerations:

   • For critically ill patients, continuous IV insulin infusion is preferred 1
   • Target blood glucose range: 140-180 mg/dL 1
   • Avoid targeting euglycemia (80-110 mg/dL) due to increased hypoglycemia risk 1

4. Transitioning from IV to Subcutaneous Insulin:

   • Calculate subcutaneous insulin requirements based on average insulin infused during previous 12 hours 1
   • Example: If average IV rate was 1.5 units/hour, estimated daily dose would be 36 units/24 hours 1

5. Premixed Insulin Considerations:

   • Premixed insulin (e.g., 70/30) is generally not recommended for hospital use due to high risk of hypoglycemia 1

By implementing a standardized protocol for Humalog administration within a basal-bolus framework, hospitals can significantly reduce medication errors and improve glycemic control while minimizing adverse events related to both hyperglycemia and hypoglycemia 2.