What is the recommended dose of Apidra (insulin glulisine) for an adult patient with type 1 or type 2 diabetes?

Apidra (Insulin Glulisine) Dosing for Adults with Diabetes

Rapid-Acting Insulin: Prandial Coverage

Apidra is a rapid-acting insulin analog used exclusively for mealtime (prandial) glucose control, not as basal insulin. It must be combined with basal insulin (like glargine or detemir) or used in insulin pump therapy 1, 2, 3.

Administration Timing and Flexibility

• Administer 0-15 minutes before meals or immediately after meals, offering significant dosing flexibility compared to regular human insulin which requires 30-minute pre-meal administration 2, 3, 4.
• Peak effect occurs at 1 hour with duration of approximately 4 hours 3.
• This rapid onset and shorter duration reduces postprandial hyperglycemia and delayed hypoglycemia risk 4.

Initial Prandial Insulin Dosing

Type 1 Diabetes

Start with total daily insulin dose of 0.5 units/kg/day, dividing 50% as basal insulin and 50% as prandial insulin (Apidra) split among three meals 5.

• For a metabolically stable 70 kg patient: Total daily dose = 35 units (17.5 units basal, 17.5 units prandial divided as approximately 6 units before each meal) 5.
• Patients in honeymoon phase may require lower doses of 0.2-0.6 units/kg/day 5.
• Higher doses (potentially exceeding 1.0 units/kg/day) are needed during puberty, pregnancy, or acute illness 5.

Type 2 Diabetes: Adding Prandial Insulin to Basal Therapy

When basal insulin alone is insufficient (fasting glucose controlled but HbA1c remains elevated), start Apidra at 4 units before the largest meal or use 10% of current basal insulin dose 5.

• Add prandial insulin when basal insulin exceeds 0.5 units/kg/day without achieving glycemic targets 5.
• For severe hyperglycemia (HbA1c ≥10-12% with symptoms), initiate basal-bolus therapy immediately with total daily dose of 0.3-0.5 units/kg/day, split 50% basal and 50% prandial 5.

Dose Titration Algorithm

Increase prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 5.

• Target postprandial glucose: <180 mg/dL 5.
• If hypoglycemia occurs, reduce the dose by 10-20% immediately 5.
• Titrate each meal's dose independently based on glucose readings 2 hours after that specific meal 5.

Carbohydrate-to-Insulin Ratio Method

For established insulin users, calculate using the 450 rule: 450 ÷ total daily insulin dose = grams of carbohydrate covered by 1 unit of Apidra 5.

• Example: Patient on 50 units total daily insulin → 450 ÷ 50 = 9 grams carbohydrate per unit.
• Common starting ratio is 1 unit per 10-15 grams of carbohydrate 5.
• Adjust ratio if postprandial glucose consistently misses target 5.

Correction (Supplemental) Dosing

Calculate insulin sensitivity factor using 1500 ÷ total daily insulin dose = mg/dL drop per unit of Apidra 5.

• Example: Patient on 50 units total daily insulin → 1500 ÷ 50 = 30 mg/dL drop per unit.
• Use this to correct pre-meal hyperglycemia above target 5.
• Avoid "stacking" correction doses within 4 hours to prevent cumulative hypoglycemia 5.

Critical Pitfalls to Avoid

Never Use Apidra as Basal Insulin

Apidra's 4-hour duration makes it completely inappropriate for basal coverage 3. Patients require separate long-acting basal insulin (glargine, detemir, or degludec) for between-meal and overnight glucose control 5, 2.

Avoid Sliding Scale Monotherapy

Scheduled prandial insulin with correction doses is superior to reactive sliding scale insulin alone, which treats hyperglycemia after it occurs rather than preventing it 5. Basal-bolus regimens improve glycemic control and reduce hospital complications compared to sliding scale monotherapy 5.

Recognize Overbasalization

When basal insulin exceeds 0.5-1.0 units/kg/day with persistent hyperglycemia, add or intensify prandial insulin rather than continuing to escalate basal insulin 5. Clinical signals include bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 5.

Special Populations

Hospitalized Patients

• For insulin-naive patients with moderate hyperglycemia (201-300 mg/dL): Start 0.2-0.3 units/kg/day total daily dose 5.
• For severe hyperglycemia (>300 mg/dL): Start 0.3 units/kg/day total daily dose, split 50% basal and 50% prandial 5.
• High-risk patients (elderly >65 years, renal failure, poor oral intake): Use lower doses of 0.1-0.25 units/kg/day 5.

Continuous Subcutaneous Insulin Infusion (Pump Therapy)

Apidra can be safely administered via insulin pump, with approximately 40-60% of total daily dose as basal delivery and remainder as mealtime boluses 5, 3.

Monitoring Requirements

• Check 2-hour postprandial glucose to guide prandial insulin adjustments 5.
• Pre-meal glucose guides correction dose calculations 5.
• Reassess HbA1c every 3 months during intensive titration 5.
• Daily self-monitoring of blood glucose is essential during titration phase 5.

Combination Therapy Considerations

Continue metformin unless contraindicated when adding or intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects 5. Consider adding GLP-1 receptor agonist to basal-bolus regimen to improve glycemic control while minimizing weight gain and hypoglycemia risk 5.