What is the initial dosing regimen for a patient on a Glucose Regulation By Sliding Scale (GRBS) using human Actrapid (insulin)?

GRBS Sliding Scale with Human Actrapid: Initial Dosing Regimen

Sliding scale insulin (SSI) alone should NOT be used as the primary insulin regimen for hospitalized patients with diabetes, as it is ineffective and strongly discouraged by current clinical guidelines. 1, 2

Why SSI Alone is Inadequate

• SSI monotherapy has been consistently shown to be ineffective in patients with established insulin requirements, achieving target glucose control in only 38% of patients versus 68% with basal-bolus regimens 1, 2
• The traditional sliding scale approach is "reactive" rather than preventive—it treats hyperglycemia after it occurs instead of preventing it, leading to rapid glucose fluctuations and both hyper- and hypoglycemia 1, 2
• SSI alone should never be used in patients with type 1 diabetes 1

Recommended Approach Instead of SSI Alone

For Non-Critically Ill Patients with Good Oral Intake:

Use a basal-bolus insulin regimen:

• Initial total daily dose: 0.3-0.5 units/kg/day for insulin-naive patients 1
• Distribution: Half as basal insulin (given once or twice daily), half as rapid-acting insulin (divided before three meals) 1
• Lower doses (0.1-0.25 units/kg/day) for high-risk patients: elderly (>65 years), renal failure, poor oral intake 1, 2
• For patients on home insulin ≥0.6 units/kg/day: Reduce total daily dose by 20% during hospitalization to prevent hypoglycemia 1

For Patients with Mild Hyperglycemia or Poor Oral Intake:

Use a basal-plus approach (preferred over SSI alone):

• Basal insulin: 0.1-0.25 units/kg/day given once daily 1, 2
• Plus correctional doses of rapid-acting insulin (like Actrapid) before meals or every 6 hours if NPO 1
• This approach is specifically recommended for patients with decreased oral intake or undergoing surgery 1, 2

For Patients Without Diabetes or Well-Controlled on Oral Agents:

SSI alone may be acceptable only in this limited scenario:

• Use correctional insulin alone for patients without diabetes or those with good metabolic control on oral medications at home 1
• However, add basal insulin if unable to maintain glucose <180 mg/dL (10 mmol/L) 1

If You Must Use Actrapid for Correctional Dosing

When using human regular insulin (Actrapid) as part of a proper regimen:

• Administer subcutaneously every 6 hours (versus every 4 hours for rapid-acting analogs) 1
• Typical correctional scale for older adults: 2 units for glucose >250 mg/dL (>13.9 mmol/L); 4 units for glucose >350 mg/dL (>19.4 mmol/L) 1
• Adjust the scheduled basal/prandial insulin doses if correctional doses are frequently required—do not continue the same sliding scale throughout hospitalization without modification 1, 2

Critical Safety Considerations

• Hypoglycemia risk: Basal-bolus regimens have 4-6 times higher hypoglycemia risk than SSI alone, but achieve far superior glycemic control 1
• The incidence of mild hypoglycemia with basal-bolus is 12-30% in controlled settings 1
• Premixed insulin (70/30) has unacceptably high hypoglycemia rates and is NOT recommended in hospitals 1, 2
• Monitor closely and reduce insulin by 10-20% if hypoglycemia occurs without clear cause 1

Common Pitfalls to Avoid

• Continuing the same sliding scale prescription throughout hospitalization despite poor control 1, 2
• Using SSI alone in type 1 diabetes—this is dangerous and should never be done 1, 2
• Failing to provide basal insulin coverage, which leads to persistent hyperglycemia 1
• Not adjusting insulin when nutritional intake changes 1