What is the recommended insulin dosing regimen for a diabetic patient using the Novolog (insulin aspart) sliding scale?

Novolog Sliding Scale: Not Recommended

Sliding-scale insulin regimens using Novolog (insulin aspart) or any rapid-acting insulin as monotherapy should be strongly discouraged in hospitalized patients, as they are ineffective and associated with worse glycemic control compared to scheduled basal-bolus insulin regimens. 1

Why Sliding Scale Fails

The fundamental problem with sliding-scale insulin is that it treats hyperglycemia after it has already occurred rather than preventing it. 1 This "reactive" approach leads to:

• Rapid glucose fluctuations that exacerbate both hyperglycemia and hypoglycemia 1
• Treatment failures - only 38% of patients achieve mean blood glucose <140 mg/dL on sliding scale alone versus 68% with basal-bolus regimens 1
• No modification throughout hospitalization - the admission sliding-scale order typically continues unchanged even when control remains poor 1
• 3-fold higher risk of hyperglycemic episodes compared to no pharmacologic treatment when used as monotherapy 2

Research demonstrates that sliding-scale insulin provides no benefit over routine diabetes medications and is associated with suboptimal glycemic control in 84% of administered doses. 2, 3

The Correct Approach: Basal-Bolus Insulin

For Non-ICU Hospitalized Patients

Use a scheduled basal-bolus-plus-correction regimen that includes: 1

• Basal insulin (long-acting): Provides continuous background insulin coverage
• Prandial insulin (rapid-acting like Novolog): Given before meals to cover nutritional intake
• Correction insulin (rapid-acting like Novolog): Supplemental doses to address acute hyperglycemia

Initial Dosing Algorithm

For insulin-naive patients with type 2 diabetes: 1

• Start with 0.4-0.5 units/kg/day total daily dose
• Give 50% as basal insulin (glargine, detemir, or NPH)
• Give 50% as prandial insulin (Novolog/aspart, lispro, or regular insulin) divided among three meals

For patients with poor oral intake or NPO status: 1

• Use basal-plus-correction insulin regimen
• Basal insulin with correction doses every 4-6 hours
• Do NOT use sliding-scale insulin alone

Correction Dose Component

While correction insulin (the "sliding scale" component) should never be used alone, it serves as an important adjunct to scheduled insulin: 1

• Use as a dose-finding strategy during initial hospitalization
• Supplement scheduled insulin when rapid changes in requirements cause hyperglycemia
• If correction doses are frequently required, increase the appropriate scheduled insulin doses rather than relying on corrections 1

Simplified Correction Scale Example

For older adults or when simplifying complex regimens: 1

• For premeal glucose >250 mg/dL (>13.9 mmol/L): give 2 units of rapid-acting insulin
• For premeal glucose >350 mg/dL (>19.4 mmol/L): give 4 units of rapid-acting insulin
• Stop the sliding scale when not needed daily 1

Glucose Targets

For most non-critically ill hospitalized patients: 1

• Target range: 7.8-10 mmol/L (140-180 mg/dL)
• More stringent targets of 6.1-7.8 mmol/L (110-140 mg/dL) may be appropriate for cardiac surgery patients or those with acute ischemic events, if achievable without significant hypoglycemia 1

Critical Pitfalls to Avoid

• Never use sliding-scale insulin as monotherapy in patients with established insulin requirements 1
• Do not continue sliding-scale-only regimens when glycemic control remains poor - this is the most common error 1
• Avoid premixed insulins in hospital settings due to unacceptably high rates of iatrogenic hypoglycemia 4
• Do not delay transition to scheduled basal-bolus regimens when sliding scale proves ineffective 1

Special Populations

For older adults (>65 years) or high-risk patients: 1, 4

• Use lower initial doses: 0.1-0.25 units/kg/day
• Consider simplified regimens with basal insulin morning dosing
• Adjust goals to 90-150 mg/dL (5.0-8.3 mmol/L) based on overall health 1

For patients on corticosteroids: 4

• Increase prandial and correction insulin by 40-60% or more in addition to basal insulin
• Single morning dose of NPH may be appropriate for patients without diabetes on steroids 4