What is the recommended prandial (before meal) insulin?

From the Guidelines

The recommended prandial (before meal) insulin is rapid-acting insulin, typically insulin lispro (Humalog), insulin aspart (NovoLog), or insulin glulisine (Apidra). These should be administered 15 minutes before meals, with dosing typically starting at 4 units per meal for adults or calculated as 0.1 U/kg per meal, or 10% of the basal insulin dose per meal if the HbA1c level is less than 8% 1. Prandial insulin works by mimicking the normal insulin spike that occurs after eating, helping to process carbohydrates and prevent post-meal blood glucose elevations. The dose should be individualized based on carbohydrate counting, pre-meal blood glucose levels, and anticipated physical activity.

Key Considerations

• The rapid-acting insulin analogues are preferred because of their quick onset of action 1.
• Providers should consider decreasing the basal insulin dose by the same amount of the starting mealtime dose 1.
• Premixed insulin products containing both basal and bolus insulin are another option for patients who may benefit from simpler dosing 1.
• Concentrated insulin preparations, such as U-500 regular insulin, may be suitable for patients requiring more than 200 units of insulin per day 1.

Monitoring and Adjustments

• Patients should monitor blood glucose before and 2 hours after meals, aiming for post-meal values below 180 mg/dL.
• Hypoglycemia is the main risk, so patients should always have fast-acting carbohydrates available and be educated on recognizing and treating low blood sugar.
• Dosing adjustments may be necessary in both mealtime and basal insulins, based on blood glucose level and an understanding of the pharmacodynamic profile of each formulation 1.

From the FDA Drug Label

APIDRA was administered subcutaneously either within 15 minutes before a meal (n=286) or immediately after a meal (n=296) and regular human insulin (n=278) was administered subcutaneously 30 to 45 minutes prior to a meal. Glycemic control (see Table 9) was comparable for the 3 treatment regimens No changes from baseline between the treatments were seen in the total daily number of short-acting insulin injections (see Table 9) APIDRA (n=277) compared to insulin lispro (n=295) when administered subcutaneously within 15 minutes before a meal Glycemic control (see Table 10) was comparable for the two treatment regimens.

The recommended prandial insulin is insulin glulisine (APIDRA) or insulin lispro, which can be administered subcutaneously within 15 minutes before a meal.

• Key points:
  • APIDRA can be administered immediately before a meal.
  • Insulin lispro is also a suitable option for prandial insulin.
  • Glycemic control is comparable between APIDRA and insulin lispro when administered before a meal. 2

From the Research

Prandial Insulin Options

The recommended prandial insulin can vary depending on individual patient needs and circumstances. Some studies suggest the following options:

• Insulin aspart, a rapid-acting insulin analog, can be used to control prandial glucose levels as part of basal-bolus therapy, in continuous subcutaneous insulin infusion, or in combination with oral antidiabetic drugs 3.
• Insulin glulisine, another rapid-acting insulin analog, may not be as effective as insulin aspart in controlling postprandial glycemic excursions in children with type 1 diabetes mellitus 4.
• Post-prandial administration of insulin aspart can provide satisfactory metabolic control in patients with type 1 diabetes mellitus 5.

Comparison of Prandial Insulins

Studies have compared the effects of different prandial insulins on postprandial glycemic excursion:

• Insulin aspart appears to be more effective than insulin glulisine in controlling 2- and 4-hour postprandial blood glucose excursions in prepubertal children with type 1 diabetes mellitus 4.
• Insulin glulisine may be a suitable choice of rapid-acting insulin for patients with type 2 diabetes who are at high risk of post-exercise hypoglycemia 6.

Types of Prandial Insulins

There are various types of prandial insulins available, including:

• Human regular insulin, which has a slower onset and extended duration 7.
• Rapid-acting analogs, such as lispro, aspart, and glulisine, which have a faster onset and shorter action duration 7.
• Ultra-rapid analogs, like faster aspart and ultra-rapid lispro, which offer even shorter onset of action 7.
• Inhaled insulins, such as Technosphere insulin, which provide an alternative route for prandial insulin delivery 7.