What is the proper protocol for prescribing short-acting insulin (SSI)?

Prescribing Short-Acting Insulin Protocol

Short-acting insulin should be administered 15 minutes before meals with dose adjustments based on pre-meal glucose levels, targeting 90-150 mg/dL before meals and <180 mg/dL post-meal. 1

Types of Short-Acting Insulin

• Regular human insulin: Begins working in 30 minutes, peaks at 2-3 hours, and lasts 5-8 hours 1
• Rapid-acting analogs (lispro, aspart, glulisine): Begin working within 15 minutes, peak at 30-90 minutes, and last less than 5 hours 2

Dosing Guidelines

Initial Dosing

• For patients new to insulin therapy requiring prandial coverage:
  • Start with 4 units per meal or 10% of the basal insulin dose 1
  • If transitioning from basal-only therapy, consider reducing basal dose by 4 units or 10% when adding prandial insulin 1

Titration

• Increase dose by 1-2 units or 10-15% twice weekly based on post-meal glucose readings 1
• If hypoglycemia occurs, determine cause and reduce corresponding dose by 10-20% 1

Simplified Sliding Scale (for initial adjustment)

• For pre-meal glucose >250 mg/dL: Add 2 units of short/rapid-acting insulin 1
• For pre-meal glucose >350 mg/dL: Add 4 units of short/rapid-acting insulin 1
• Stop sliding scale when not needed daily 1

Administration Timing

• Regular insulin: Administer 15-30 minutes before meals 3
• Rapid-acting analogs: Administer 0-15 minutes before meals 3
• Do not use rapid or short-acting insulin at bedtime due to risk of nocturnal hypoglycemia 1

Mixing Guidelines

• Visual inspection before use: rapid and short-acting insulins should appear clear 1
• When mixing with other insulins:
  • Rapid-acting insulin can be mixed with NPH insulin 1
  • When rapid-acting insulin is mixed with intermediate/long-acting insulin, inject within 15 minutes before a meal 1
  • Insulin glargine should NOT be mixed with other insulins due to its low pH 1
  • Avoid mixing short-acting and lente insulins unless patient is already well-controlled on this mixture 1

Monitoring Protocol

• Check blood glucose before meals and 2 hours after meals 4
• Target ranges:
  • Fasting and pre-meal: 80-130 mg/dL 4
  • 2-hour post-meal: <180 mg/dL 4
• For hospitalized patients, maintain blood glucose <180 mg/dL to minimize complications 5

Adjusting for Special Situations

Hospital Setting

• In non-critical care settings, use scheduled insulin orders rather than sliding scale alone 1
• Align insulin injections with meals for patients who are eating 1
• For patients with poor oral intake, consider basal insulin with correction doses 1

Older Adults

• Consider simplifying regimen for older adults with limited self-management abilities 1
• For older adults with prandial insulin ≤10 units/dose: Consider discontinuing prandial insulin and adding non-insulin agents 1
• For older adults with prandial insulin >10 units/dose: Decrease dose by 50% and add non-insulin agent 1

Common Pitfalls to Avoid

• Avoid using sliding scale insulin as the sole method of treatment 1
• Never recap, bend, or break needles to prevent needle-stick injuries 1
• Do not store insulin in extreme temperatures (<36°F or >86°F) to maintain potency 1
• Avoid administering short-acting insulin at bedtime to prevent nocturnal hypoglycemia 1
• Be cautious with insulin dosing during periods of variable food intake or acute illness 1