What is a normal sliding scale for rapid-acting (e.g. aspart or lispro) insulin dosing?

Normal Sliding Scale for Rapid-Acting Insulin

A normal sliding scale for rapid-acting insulin typically starts with 2 units for blood glucose >250 mg/dL and 4 units for blood glucose >350 mg/dL before meals, with adjustments based on individual patient response. 1

Recommended Starting Doses

• The recommended starting dose of mealtime insulin is 4 units, 0.1 units/kg, or 10% of the basal dose 1
• If A1C is <8% when starting mealtime bolus insulin, consider decreasing the basal insulin dose 1
• For premeal glucose >250 mg/dL (>13.9 mmol/L), give 2 units of rapid-acting insulin 1
• For premeal glucose >350 mg/dL (>19.4 mmol/L), give 4 units of rapid-acting insulin 1

Titration and Adjustment

• Adjust insulin doses every 2 weeks based on fingerstick glucose testing performed before lunch and before dinner 1
• Target premeal glucose range: 90–150 mg/dL (5.0–8.3 mmol/L) 1
• If 50% of premeal fingerstick values over 2 weeks are above goal, increase the dose by 2 units 1
• If >2 premeal fingerstick values/week are <90 mg/dL (5.0 mmol/L), decrease the dose of medication 1

Important Considerations

• Do not use rapid-acting insulin at bedtime due to risk of nocturnal hypoglycemia 1, 2
• Stop sliding scale when not needed daily 1
• Rapid-acting insulins (aspart, lispro, glulisine) are preferred for mealtime dosing due to their prompt onset of action 1, 3
• Sliding scale insulin alone (without basal insulin) is associated with a 3-fold higher risk of hyperglycemic episodes compared to no pharmacologic regimen 4

Special Populations

• For older adults, consider using a simplified sliding scale during insulin adjustment periods 1
• In patients with wide glucose excursions, consider simplifying the insulin regimen further 1
• For patients with cognitive or functional decline, a simpler regimen with fewer daily injections may be preferred 2

Preventing Common Pitfalls

• Avoid overlapping insulin regimens that can lead to insulin stacking and hypoglycemia 2
• When using both basal and prandial insulin, maintain consistent timing between doses 2
• For patients transitioning between insulin regimens, maintain the same total daily dose initially but adjust the distribution 2
• Check blood glucose more frequently during transition periods between insulin regimens 2, 5

Using a structured approach to rapid-acting insulin sliding scales with appropriate monitoring and adjustments helps optimize glycemic control while minimizing the risk of hypoglycemia.