What is the sliding scale (SS) protocol for aspart (novolog) insulin in managing hyperglycemia?

Sliding Scale Protocol for Aspart (Novolog) Insulin in Managing Hyperglycemia

Sliding scale insulin alone is strongly discouraged for managing hyperglycemia in hospitalized patients and should be replaced with a basal-bolus regimen that includes aspart as the rapid-acting component. 1, 2

Recommended Approach: Basal-Bolus Regimen

Initial Dosing

• For insulin-naive patients:
  • Total daily dose: 0.3-0.5 units/kg/day
  • Distribution: 50% basal insulin (glargine/detemir), 50% prandial aspart
  • Example for 70kg patient: 21-35 units total daily dose
    • Basal: 10-17.5 units once daily
    • Prandial aspart: 3-6 units per meal

Dose Adjustments for Special Populations

• For patients at higher risk of hypoglycemia:

  • Elderly (>65 years)
  • Renal impairment
  • Poor oral intake
  • Use lower starting dose: 0.2-0.3 units/kg/day 2

• For patients on higher home insulin doses (≥0.6 units/kg/day):

  • Reduce total daily dose by 20% while hospitalized 2

Correction Dose (Supplemental) Protocol for Aspart

When used as part of a basal-bolus regimen, the following sliding scale can be implemented for correction doses:

Low-Dose Scale (insulin sensitive, elderly, renal impairment):

• BG 140-180 mg/dL: 1 unit aspart
• BG 181-220 mg/dL: 2 units aspart
• BG 221-260 mg/dL: 3 units aspart
• BG 261-300 mg/dL: 4 units aspart
• BG >300 mg/dL: 5 units aspart and notify provider

Moderate-Dose Scale (most patients):

• BG 140-180 mg/dL: 2 units aspart
• BG 181-220 mg/dL: 4 units aspart
• BG 221-260 mg/dL: 6 units aspart
• BG 261-300 mg/dL: 8 units aspart
• BG >300 mg/dL: 10 units aspart and notify provider

High-Dose Scale (insulin resistant, BMI >30, receiving steroids):

• BG 140-180 mg/dL: 3 units aspart
• BG 181-220 mg/dL: 6 units aspart
• BG 221-260 mg/dL: 9 units aspart
• BG 261-300 mg/dL: 12 units aspart
• BG >300 mg/dL: 15 units aspart and notify provider

Alternative: Basal-Plus Approach

For patients with poor oral intake or NPO status:

• Basal insulin: 0.1-0.25 units/kg/day
• Correction doses of aspart as per scale above
• No scheduled prandial doses 1, 2

Monitoring and Adjustment

• For patients eating: Check BG before meals and at bedtime
• For NPO patients: Check BG every 4-6 hours
• Adjust insulin doses daily based on patterns:
  • If fasting BG consistently >140 mg/dL: Increase basal insulin by 10-20%
  • If pre-meal BG consistently >140 mg/dL: Increase previous meal's aspart dose by 10-20%
  • If hypoglycemia occurs: Decrease corresponding insulin dose by 20-40%

Pitfalls and Caveats

1. Avoid sliding scale insulin monotherapy: Traditional sliding scale insulin regimens without basal insulin have been shown to be ineffective and are associated with poor glycemic control 1, 2. A study demonstrated that glycemic control (defined as mean blood glucose <140 mg/dL) was achieved in only 38% of patients receiving sliding scale insulin alone compared to 68% with basal-bolus insulin therapy 1.

2. Recognize increased hypoglycemia risk: Basal-bolus regimens have a 4-6 times higher risk of hypoglycemia compared to sliding scale alone 1. Monitor closely for blood glucose <70 mg/dL.

3. Adjust for continuous enteral feeding: For patients on continuous tube feeding, consider NPH insulin every 4-6 hours instead of aspart sliding scale, as this has been shown to provide better glycemic control 3.

4. Consider IV insulin for critical illness: For critically ill patients, continuous IV insulin infusion is preferred over subcutaneous aspart, targeting a blood glucose range of 140-180 mg/dL 2.

5. Avoid premixed insulin: Premixed insulin formulations have been associated with an unacceptably high rate of hypoglycemia and are not recommended for hospital use 1, 2.

By implementing a standardized protocol for insulin aspart administration as part of a comprehensive insulin regimen rather than relying solely on sliding scale insulin, medication errors can be reduced and glycemic control improved, potentially reducing hospital length of stay 4, 5.