SSI with novolog/humalog vs regular insulin

[meerkat111]

Hi All,
I am used to using humalog/novolog insulin for SSI orders. My hospital has regular insulin SSI. Once injected, Regular insulin takes 30 minutes to begin working, peaks between 2 and 4 hours and hangs on for 6 to 8 hours, long after the meal stopped raising the blood sugar. Humalog and Novolog, on the other hand, begin working in about 10 minutes, peaks at one to one and a half hours and are gone in about three and a half to four hours.

Just curious to know if you have seen one work better than the other? It seems like humalog/novolog are indeed better than regular for meal coverage...
Thanks!

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[CopaceticOne]

Here's how I think about it:

• Regular is for NPO, continuous tube feeds, continuous TPN.
• Humalog/Novolog is for people eating.

But there is a cost aspect, so that may be why only Regular is formulary at your hospital. Everything in medicine is ideal/optimal vs. acceptable.

 

[rokshana]

Hi All,
I am used to using humalog/novolog insulin for SSI orders. My hospital has regular insulin SSI. Once injected, Regular insulin takes 30 minutes to begin working, peaks between 2 and 4 hours and hangs on for 6 to 8 hours, long after the meal stopped raising the blood sugar. Humalog and Novolog, on the other hand, begin working in about 10 minutes, peaks at one to one and a half hours and are gone in about three and a half to four hours.

Just curious to know if you have seen one work better than the other? It seems like humalog/novolog are indeed better than regular for meal coverage...
Thanks!

the correction scale insulin should be the same insulin as the scheduled mealtime insulin...meaning if regular insulin is used with meals then the correction should be regular...if the mealtime insulin is Novolog/Humalog, the the correction is Novolog/Humalog.

and FYI SSI is a misnomer for what is being used in the hospital...it is a correction scale.

 

[NRAI2001]

Just got done with my endocrine rotation.... the endocrinologist would kill you at even the mention of using a SSI.

 

[meerkat111]

Just go at done with my endocrine rotation.... the endocrinologist logist would kill you at eventhe mention of using a SSI.

Well, the realty is, in a hospital setting some times I watch them with this type of scale to figure out how much they are needing it and given them long acting the following day.

 

[the argus]

Just go at done with my endocrine rotation.... the endocrinologist logist would kill you at eventhe mention of using a SSI.

As mentioned above, I think there's some confusion about semantics.

The strict definition of sliding scale insulin (i.e. what endocrinologists are referring to when they use the term) is different from what general IM people mean when they say sliding scale (I assume like the OP above)

In strictest terms,
1. sliding scale insulin strategy - term for insulin strategy where the only insulin a patient receives during the day is short or rapid-acting insulin based on a sliding scale depending on the patient's premeal fingersticks. There is no basal insulin being given.

2. basal/bolus insulin strategy - patient gets a set amount of basal (i.e. long acting) insulin daily, as well as a set amount of rapid/short acting insulin before meals with an additional "correction scale" amount of rapid/short acting insulin before each meal depending on their premeal fingerstick. In the hospital, we would then add the total amount of correction scale insulin given the previous day to the basal/bolus doses (half goes to basal insulin, half is split among scheduled premeal insulin doses)


When a general internist in the hospital setting says "sliding scale" nowadays, they are almost always referring to the correction scale insulin within a basal/bolus strategy. When your endocrinologist attending doesn't like "sliding scale insulin", they are referring to a sliding scale insulin strategy in the strictest terms (#1 above).

 

[rokshana]

Well, the realty is, in a hospital setting some times I watch them with this type of scale to figure out how much they are needing it and given them long acting the following day.

no what they are doing in the hospital IS a correction scale...reactively giving insulin based on a blood sugar over a certain number ...usually starts at 140-150...a sliding scale utilizes differing amounts of insulin to be given proactively based on the premeal sugar...this starts at a regular sugar like 80.

 

[Raryn]

Here's how I think about it:

• Regular is for NPO, continuous tube feeds, continuous TPN.
• Humalog/Novolog is for people eating.

But there is a cost aspect, so that may be why only Regular is formulary at your hospital. Everything in medicine is ideal/optimal vs. acceptable.

It's a bit of a misconception really.

So for a patient on continuous tube feeding/TPN, you can give *scheduled* NPH, Regular, Lantus, etc. etc. without any problem. Anything works, and you'll see different endocrinologists approach it different ways. At the institution where I'm at, people on continuous feeding get BID Lantus for their entire scheduled requirement, with one of the two doses held if they're ever NPO. Where I did residency, they got scheduled q6h regular.

For *correctional* insulin (what is administered as a "sliding scale"), anyone can get the rapid acting insulins. NPO, tube feeding, whatever. The reason is this: scheduled insulins are proactive, you give them for the carbohydrates you're about to eat (or make via gluconeogenesis). OTOH, correctional insulin is reactive, you give it for the sugar already in the serum. Therefore, you can give every single person rapid acting insulin as their correctional scale (even if they're NPO) and assuming you havent totally misdosed it, it will be perfectly safe.

I have everyone inpatient on rapid acting correctional unless they're on scheduled regular for some reason (basically only if they're pregnant and their Ob is old school and only prescribed NPH/regular). It works faster and you're much less likely to get insulin stacking if the nurse rechecks a sugar a bit early.

Regardless though, the data is eminently clear: There is almost never an indication for a patient, inpatient or outpatient, to be on correctional insulin only. If they have any sort of insulin requirement, they should at the very least have a basal on board. Basal+correction is a valid strategy in a type 2 who might be eating inconsistently, though basal+bolus+correction is better for glycemic control.

(And the argument about terms is fairly pedantic in that we all know what people are referencing if they say sliding scale, even if it isn't entirely correct)