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.

Carbohydrate-to-Insulin Ratio Method

• Starting ratio: 1 unit per 10-15 grams of carbohydrate 5.
• Calculate individualized ratio using formula: 500 ÷ total daily insulin dose (for regular insulin) or 450 ÷ total daily insulin dose (for rapid-acting analogs like Apidra) 5.
• Adjust the carbohydrate-to-insulin ratio if postprandial glucose consistently remains out of target 5.

Correction (Supplemental) Dosing

Calculate insulin sensitivity factor (ISF) using: 1500 ÷ total daily insulin dose 5.

• This determines how many mg/dL one unit of Apidra will lower blood glucose (typically 30-50 mg/dL per unit) 5.
• Adjust ISF, not basal insulin, if correction doses consistently fail to bring glucose into target range 5.
• Avoid "stacking" correction doses within 4 hours as insulin from previous dose remains active 5.

Critical Thresholds and Warning Signs

Recognizing Overbasalization

Stop escalating basal insulin when dose exceeds 0.5 units/kg/day; instead, add or intensify prandial Apidra 5.

Clinical signals requiring prandial insulin addition include:

• Basal insulin dose >0.5 units/kg/day 5
• Bedtime-to-morning glucose differential ≥50 mg/dL 5
• Recurrent hypoglycemia 5
• High glucose variability 5
• Fasting glucose controlled but HbA1c remains elevated after 3-6 months 5

Special Populations and Situations

Continuous Subcutaneous Insulin Infusion (Pump Therapy)

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

Hospitalized Patients

• For insulin-naive hospitalized 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.
• Reduce home insulin dose by 20% for patients on high-dose insulin (≥0.6 units/kg/day) to prevent hypoglycemia 5.

Renal Impairment

• Lower doses (0.1-0.25 units/kg/day total daily insulin) recommended for high-risk patients including elderly (>65 years), those with renal failure, or poor oral intake 5.

Common Pitfalls to Avoid

• Never use Apidra as basal insulin - it is exclusively for mealtime coverage 1, 2, 3.
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without adding prandial coverage - this causes overbasalization with increased hypoglycemia risk 5.
• Avoid relying solely on sliding scale (correction) insulin - scheduled basal-bolus regimens are superior 5.
• Do not mix or dilute Apidra with other insulins - administer as separate injection 5.
• Continue metformin when adding insulin unless contraindicated - it reduces insulin requirements and weight gain 5, 4.

Monitoring Requirements

• Daily self-monitoring of fasting and 2-hour postprandial glucose is essential during titration 5.
• Check HbA1c every 3 months during intensive titration 5.
• Reassess insulin doses at every clinical visit, looking for signs of overbasalization 5.

Comparative Efficacy

Apidra demonstrates similar glycemic control to insulin lispro and superior control compared to regular human insulin, with faster onset allowing flexible meal-time administration 1, 3, 6. Hypoglycemia rates are comparable to other rapid-acting insulin analogs 1, 6.