What is the recommended insulin sliding scale for a patient with diabetes using Apidra (insulin glulisine)?

Sliding Scale Insulin Should Not Be Used as Monotherapy for Apidra

Sliding scale insulin (SSI) as the sole treatment approach is explicitly condemned by the American Diabetes Association and should be immediately replaced with a scheduled basal-bolus insulin regimen for any patient with established diabetes. 1

Why Sliding Scale Fails

Sliding scale insulin treats hyperglycemia reactively after it has already occurred rather than preventing it, leading to dangerous glucose fluctuations that worsen both hyperglycemia and hypoglycemia. 1, 2

• Only 38% of patients achieve mean blood glucose <140 mg/dL on sliding scale alone versus 68% with basal-bolus regimens. 1
• SSI provides no benefit when used alone and is associated with a 3-fold higher risk of hyperglycemic episodes compared to no pharmacologic treatment. 3
• Randomized trials consistently demonstrate that basal-bolus approaches reduce postoperative complications including wound infections and acute renal failure compared to SSI monotherapy. 2

The Correct Approach: Basal-Bolus Insulin with Apidra

For hospitalized patients, the Endocrine Society recommends a scheduled basal-bolus-plus-correction regimen that includes basal insulin (such as glargine or detemir), prandial insulin (Apidra before meals), and correction insulin for hyperglycemia. 1

Initial Dosing Algorithm

For insulin-naive patients or those on low-dose insulin:

• Start with total daily dose of 0.4-0.5 units/kg/day (0.3-0.5 units/kg for hospitalized patients). 1, 2
• Give 50% as basal insulin once daily (glargine or detemir). 1
• Give 50% as prandial Apidra divided among three meals (before breakfast, lunch, and dinner). 1

For high-risk patients (elderly >65 years, renal failure, poor oral intake):

• Use lower initial doses of 0.1-0.25 units/kg/day. 1, 4

For patients already on high-dose home insulin (≥0.6 units/kg/day):

• Reduce total daily dose by 20% upon hospitalization to prevent hypoglycemia. 4, 2

Apidra Administration Timing

• Apidra (insulin glulisine) is a rapid-acting insulin that must be given 0-15 minutes before meals, not after eating. 5
• Each pre-meal dose should be approximately one-third of the total prandial insulin allocation. 1

Correction Insulin with Apidra

Correction doses of Apidra should supplement—not replace—scheduled prandial doses:

• Use correction insulin for blood glucose >140-180 mg/dL based on individualized insulin sensitivity factor. 1, 2
• Calculate insulin sensitivity factor as 1500 ÷ total daily dose. 4
• If correction doses are frequently required, increase the scheduled basal or prandial insulin doses accordingly rather than relying on corrections alone. 2

Glucose Targets

• Target glucose range of 140-180 mg/dL for most non-critically ill hospitalized patients. 1, 2
• More stringent targets of 110-140 mg/dL may be appropriate for cardiac surgery patients or those with acute ischemic events. 1

Special Situations Where Limited SSI Might Be Acceptable

The American Diabetes Association suggests SSI might be acceptable only in highly specific circumstances: 2

• Mild stress hyperglycemia in patients without pre-existing diabetes
• Well-controlled diabetes (HbA1c <7%) on minimal home therapy with only mild hyperglycemia during hospitalization
• Patients who are NPO with no nutritional replacement and only mild hyperglycemia
• Patients newly started on steroids or tapering steroids

However, even in these situations, if hyperglycemia persists, transition immediately to scheduled basal-bolus insulin. 2

Critical Pitfalls to Avoid

• Never use SSI as monotherapy in patients with established insulin requirements—this approach is associated with worse outcomes and higher complication rates. 1, 6
• Never continue SSI throughout hospitalization without modification when glycemic control remains poor. 2
• Avoid premixed insulins (70/30) in hospital settings due to unacceptably high rates of iatrogenic hypoglycemia. 1, 2
• Do not abruptly discontinue oral diabetes medications when starting insulin therapy due to risk of rebound hyperglycemia. 5

Monitoring and Titration

• Adjust basal insulin based on fasting glucose values every 3 days. 4
• Adjust prandial Apidra doses based on pre-meal and 2-hour postprandial glucose readings. 4
• If hypoglycemia occurs, reduce the relevant insulin component by 10-20% immediately. 1, 4