Low Dose Sliding Scale Insulin Lispro Protocol for Acute Coronary Syndrome
For patients with Acute Coronary Syndrome (ACS) and hyperglycemia, a dose-adjusted insulin lispro sliding scale should be implemented to maintain blood glucose between 5.0-11.0 mmol/L (90-200 mg/dL) while avoiding hypoglycemia. 1
Recommended Low Dose Sliding Scale for Insulin Lispro (AC and HS)
| Blood Glucose (mg/dL) | Blood Glucose (mmol/L) | Insulin Lispro Dose (units) |
|---|---|---|
| <90 | <5.0 | No insulin, check glucose in 1 hour |
| 90-140 | 5.0-7.8 | 0 units |
| 141-180 | 7.9-10.0 | 2 units |
| 181-220 | 10.1-12.2 | 3 units |
| 221-260 | 12.3-14.4 | 4 units |
| 261-300 | 14.5-16.7 | 5 units |
| 301-350 | 16.8-19.4 | 6 units |
| >350 | >19.4 | 6 units and notify physician |
Implementation Guidelines
- Administer insulin lispro immediately before or after meals (AC) and at bedtime (HS) 1
- Monitor blood glucose at initial evaluation and repeat frequently in patients with known diabetes or hyperglycemia 1
- Target glucose levels ≤11.0 mmol/L (200 mg/dL) while avoiding hypoglycemia (<5.0 mmol/L or 90 mg/dL) 1
- Consider less stringent glucose control in patients with more advanced cardiovascular disease, older age, longer diabetes duration, and more comorbidities 1
Monitoring and Adjustments
- Check blood glucose before meals and at bedtime (minimum 4 times daily) 1
- For patients with persistent hyperglycemia despite sliding scale insulin, consider adding basal insulin or transitioning to a basal-bolus regimen 1
- If hypoglycemia occurs, immediately treat with 15-20g of fast-acting carbohydrates and recheck glucose in 15 minutes 1
Important Considerations
- Sliding scale insulin alone is often ineffective for optimal glycemic control and may lead to glucose variability 2
- Regular monitoring is essential as insulin requirements may change during the acute phase of ACS 1
- Insulin lispro has a faster onset and shorter duration compared to regular insulin, which may help reduce postprandial hyperglycemia but requires careful monitoring to prevent hypoglycemia 3
- In patients with moderate to high insulin resistance, be cautious with lispro as it may cause increased glucose variability due to its short duration of action 4
Cautions and Pitfalls
- Avoid hypoglycemia at all costs as it is associated with adverse outcomes in ACS patients 1
- Standardized protocols reduce medication errors and adverse events related to sliding scale insulin 5
- Ensure proper documentation of glucose measurements and insulin administration to maintain treatment continuity 2
- For patients on metformin, monitor renal function carefully for at least 3 days after coronary angiography/PCI 1
This sliding scale should be adjusted based on individual patient response, with particular attention to preventing both hypoglycemia and persistent hyperglycemia, as both conditions are associated with increased mortality and complications in ACS patients.