What is the appropriate dosage of Actrapid (human insulin) based on capillary blood glucose (CBG) levels?

Actrapid Dosing Based on Capillary Blood Glucose Levels

Sliding scale insulin (SSI) alone should be strongly avoided as it is associated with worse glycemic control and increased hyperglycemic episodes compared to scheduled basal-bolus regimens. 1, 2

Critical Context: Sliding Scale Insulin is Inadequate Monotherapy

• Using Actrapid (regular insulin) as sliding scale only is strongly discouraged by the American Diabetes Association and provides no benefit when used without scheduled basal insulin. 1
• Research demonstrates that SSI alone increases the risk of hyperglycemic episodes 3-fold compared to no pharmacologic treatment, with rates of hyperglycemia reaching 40% of patients. 2
• The Endocrine Society explicitly recommends against using sliding scale insulin alone as the primary regimen in patients requiring insulin therapy. 3

Proper Actrapid Dosing Strategy

If Actrapid Must Be Used (Correction Insulin Component)

Correction doses should supplement—not replace—scheduled basal and prandial insulin:

• For pre-meal CBG >250 mg/dL (13.9 mmol/L): Give 2 units of rapid-acting insulin 3
• For pre-meal CBG >350 mg/dL (19.4 mmol/L): Give 4 units of rapid-acting insulin 3
• These correction doses must be added to carbohydrate coverage insulin, not used in isolation. 3

Scheduled Prandial Dosing (Preferred Approach)

Actrapid should be dosed as scheduled prandial insulin before meals:

• Start with 4 units per meal or 10% of the basal insulin dose with the largest meal. 3
• Calculate using insulin-to-carbohydrate ratio: typically 1 unit per 10-15 grams of carbohydrate consumed. 4, 3
• Increase by 1-2 units or 10-15% twice weekly based on postprandial glucose levels measured 2-3 hours after meals. 3

Basal Insulin Requirements

Actrapid cannot function as basal insulin—a long-acting insulin must be prescribed concurrently:

• Initiate basal insulin (NPH, glargine, detemir, or degludec) at 10 units daily or 0.1-0.2 units/kg. 1, 3
• Titrate basal insulin by 2 units every 3 days to achieve fasting glucose target of 90-150 mg/dL (5.0-8.3 mmol/L). 3
• When adding prandial insulin, reduce basal dose by 4 units or 10%. 3

Target Blood Glucose Ranges

• Aim for CBG levels of 140-180 mg/dL (7.8-10.0 mmol/L) in non-critically ill hospitalized patients. 4
• For outpatients on intensive insulin therapy, achieving approximately 60% of CBG readings between 4-10 mmol/L (72-180 mg/dL) correlates with HbA1c <7.5%. 5
• Fasting glucose target should be 90-150 mg/dL for most patients. 3

Critical Monitoring and Safety

Institutions must implement policies requiring physician notification for CBG results outside specified ranges:

• Notify physician for CBG <50 mg/dL (<2.8 mmol/L) or >350 mg/dL (>19.4 mmol/L). 1
• Check CBG immediately in patients exhibiting altered mental status, agitation, or diaphoresis. 1
• Treat hypoglycemia (CBG <70 mg/dL) with 15-20 grams oral glucose and recheck at 15-minute intervals. 1
• Glucagon for intramuscular injection must be available for severe hypoglycemia without requiring patient transport. 1

Common Pitfalls to Avoid

• Never rely on Actrapid sliding scale alone—this consistently shows worse outcomes than basal-bolus regimens. 1, 2
• Do not forget nutritional insulin coverage for patients receiving continuous enteral nutrition or regular meals. 4
• Avoid delaying insulin dose titration—adjust every 2 weeks based on glucose patterns. 3
• For hypoglycemia without clear cause, reduce insulin dose by 10-20% immediately. 3

Special Populations

Hemodialysis patients require lower insulin doses and closer monitoring:

• Use lower starting doses (0.3 units/kg total daily dose) for patients at higher hypoglycemia risk, including those with renal failure. 3
• Hemodialysis patients are at significantly higher risk for hypoglycemia and typically require dose reductions. 4