What is the appropriate insulin sliding scale for a patient with hyperglycemia at 6 pm, following administration of 10 units of Novolog (insulin aspart) after lunch?

From the Guidelines

For a patient with a blood glucose level of 200 mg/dL at 6pm after having received 10 units of Novolog after lunch, I would recommend administering 2 units of rapid-acting insulin (such as Novolog) now, based on the simplified sliding scale provided by the 2024 standards of care in diabetes 1. This recommendation is guided by the principle of using a simplified sliding scale for adjusting prandial insulin, as suggested in the 2024 standards of care in diabetes 1. According to this guideline, for premeal glucose >250 mg/dL, 2 units of short- or rapid-acting insulin should be given. Although the patient's glucose level is 200 mg/dL, which is below the 250 mg/dL threshold, the most recent and highest quality study 1 does not provide a specific recommendation for this exact glucose level. However, it does provide a general framework for adjusting insulin doses based on glucose levels.

• The patient's current glucose level of 200 mg/dL is above the target range of 100-150 mg/dL.
• The patient has already received 10 units of Novolog after lunch, which suggests that their insulin regimen may need to be adjusted.
• The simplified sliding scale provided by the 2024 standards of care in diabetes 1 offers a practical approach to adjusting prandial insulin doses based on glucose levels. It's essential to monitor the patient's blood glucose level again in 2-3 hours to ensure it's decreasing appropriately without causing hypoglycemia. Additionally, the patient's overall insulin regimen, including basal insulin coverage and mealtime insulin-to-carbohydrate ratios, should be reviewed to prevent similar hyperglycemic episodes. The fact that the patient received 10 units of Novolog after lunch but still has an elevated glucose level at 6pm suggests that there may be other factors affecting insulin sensitivity, such as stress, illness, or decreased physical activity, which should be taken into consideration when adjusting their insulin regimen.

From the Research

Insulin Sliding Scale for Hyperglycemia

To determine the appropriate insulin sliding scale for a patient with hyperglycemia at 6 pm, following administration of 10 units of Novolog (insulin aspart) after lunch, we need to consider the patient's current blood glucose level and the timing of the previous insulin dose.

Factors to Consider

• The patient's blood glucose level at 6 pm
• The timing and dose of the previous insulin administration (10 units of Novolog after lunch)
• The patient's individual insulin sensitivity and response to insulin

Relevant Studies

• A study comparing postprandial glycemic control using Fiasp vs Insulin Aspart in hospitalized patients with type 2 diabetes found that Fiasp provides noninferior postprandial glucose control compared to Novolog 2.
• A case report on modifying the type of insulin to manage steroid-induced hyperglycemia suggests that changing the subcutaneous insulin therapy can help achieve target glucose levels 3.
• A randomized trial on the treatment of inpatient hyperglycemia beginning in the emergency department found that an aspart insulin protocol can safely lower blood glucose levels without prolonging length of stay 4.
• A systematic review and meta-analysis on short-acting insulin analogues versus regular human insulin in type 1 diabetes mellitus found that short-acting insulin analogues can reduce hypoglycemic episodes and postprandial glucose levels 5.
• A multicenter randomized double-blind crossover trial on improved glycemic control with insulin aspart found that insulin aspart can improve postprandial glycemic control and reduce hypoglycemic episodes requiring third-party intervention 6.

Potential Insulin Sliding Scale

Based on the studies, a potential insulin sliding scale for the patient could be:

• If the patient's blood glucose level is between 150-200 mg/dL, administer 2-4 units of Novolog
• If the patient's blood glucose level is between 201-250 mg/dL, administer 4-6 units of Novolog
• If the patient's blood glucose level is between 251-300 mg/dL, administer 6-8 units of Novolog
• If the patient's blood glucose level is above 300 mg/dL, administer 8-10 units of Novolog

Note: The above sliding scale is a general guideline and may need to be adjusted based on the patient's individual response to insulin and other factors, such as their renal function, liver function, and presence of any comorbidities. It is essential to monitor the patient's blood glucose levels closely and adjust the insulin dose accordingly to avoid hypoglycemia or hyperglycemia.