What is the recommended dosing of Actrapid (human insulin) for a patient with diabetes?

Actrapid Insulin Dosing

For type 2 diabetes, start Actrapid at 4 units before each meal (or 10% of your basal insulin dose if already on basal insulin), administered 0-30 minutes before eating, and increase by 1-2 units every 3 days until 2-hour post-meal glucose is below 180 mg/dL. 1

Initial Dosing Strategy

Type 2 Diabetes Patients

• Start with 4 units of Actrapid before the largest meal when adding prandial coverage to existing basal insulin 1
• Alternatively, use 10% of current basal insulin dose as the starting prandial dose 1
• Administer 0-30 minutes before meals for optimal postprandial control—Actrapid given immediately before meals provides comparable control to administration 30 minutes prior 2
• For patients not on basal insulin but requiring immediate intensive therapy (A1C ≥10%, glucose ≥300 mg/dL), initiate basal-bolus regimen with 0.3-0.5 units/kg/day total, split 50% basal and 50% prandial 1, 3

Type 1 Diabetes Patients

• Total daily insulin requirement: 0.4-1.0 units/kg/day, with approximately 50% as prandial insulin divided among three meals 1, 4
• For a metabolically stable patient, use 0.5 units/kg/day total, giving 50% as basal and 50% as Actrapid split across meals 1
• Example: 70 kg patient = 35 units total daily, with approximately 17.5 units as prandial insulin = roughly 6 units before each meal 1

Titration Protocol

Dose Adjustment Algorithm

• Increase by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1
• Target postprandial glucose <180 mg/dL (10 mmol/L) 1
• If hypoglycemia occurs without clear cause, reduce dose by 10-20% immediately 1

Carbohydrate-Based Dosing (Advanced)

• Calculate insulin-to-carbohydrate ratio: 450 ÷ total daily insulin dose 1
• Example: If total daily insulin = 50 units, ratio = 450÷50 = 9 grams carbohydrate per 1 unit insulin 1
• Add correction dose using insulin sensitivity factor: 1500 ÷ total daily dose 1

Administration Timing

Critical timing difference from rapid-acting analogues:

• Actrapid should be given 0-30 minutes before meals, whereas rapid-acting analogues (like Aspart) can be given 0-15 minutes before 4, 2
• Administering Actrapid 30 minutes before meals provides better postprandial control than immediate pre-meal injection 2
• Never administer at bedtime—this dramatically increases nocturnal hypoglycemia risk 1

Special Clinical Situations

Hospitalized Patients

• For non-critically ill patients eating regular meals: 0.5 units/kg/day total, with 50% as basal and 50% as Actrapid divided before meals 1
• For high-risk patients (elderly >65 years, renal impairment, poor intake): reduce to 0.3 units/kg/day 1
• Check glucose before each meal and at bedtime, targeting 140-180 mg/dL 5, 1

Renal Impairment

• CKD Stage 5 with type 2 diabetes: reduce total daily dose by 50% 1
• CKD Stage 5 with type 1 diabetes: reduce total daily dose by 35-40% 1
• Titrate conservatively with eGFR <45 mL/min/1.73 m² 1

Patients on Corticosteroids

• Increase prandial insulin by 40-60% in addition to basal adjustments 1
• Consider NPH in morning for daytime steroid-induced hyperglycemia 6

Critical Thresholds and Warning Signs

When to Add Prandial Insulin

• Basal insulin optimized (fasting glucose 80-130 mg/dL) but A1C remains above target after 3-6 months 1
• Basal insulin dose exceeds 0.5 units/kg/day without achieving glycemic goals 1
• Significant postprandial excursions (>180 mg/dL) despite adequate fasting control 1

Signs of Overbasalization (Stop Escalating Basal, Add Prandial)

• Basal insulin dose >0.5 units/kg/day 1
• Bedtime-to-morning glucose drop ≥50 mg/dL 1
• Recurrent hypoglycemia 1
• High glucose variability throughout the day 1

Common Pitfalls to Avoid

• Never use sliding scale insulin as monotherapy—it treats hyperglycemia reactively rather than preventing it, leading to dangerous fluctuations 5, 1
• Never continue metformin discontinuation when starting insulin—metformin should be continued unless contraindicated, as it reduces insulin requirements and weight gain 1, 4
• Never inject intramuscularly into the thigh with long-acting insulins—severe hypoglycemia may result, though IM injection of Actrapid specifically may provide faster absorption 4, 7
• Never delay prandial insulin addition when blood glucose remains in 200s mg/dL despite basal optimization—this indicates need for mealtime coverage 1
• Avoid needle reuse—associated with lipohypertrophy which distorts insulin absorption, though patients who reuse should not be subjected to alarming claims of excessive morbidity 4

Monitoring Requirements

• Daily pre-meal glucose checks during titration phase 1
• 2-hour postprandial glucose to assess prandial insulin adequacy 1
• A1C every 3 months during intensive titration 1
• Rotate injection sites to prevent lipohypertrophy 4
• Use 4-mm pen needles as first-line choice—safest, most effective, and less painful 4

Foundation Therapy Considerations

• Continue metformin at maximum tolerated dose (up to 2000-2500 mg daily) when adding Actrapid—this combination provides superior control with less weight gain 1, 4
• Consider discontinuing sulfonylureas when advancing to basal-bolus therapy to prevent hypoglycemia 1
• GLP-1 receptor agonists may be added to basal insulin before advancing to full basal-bolus regimen, providing comparable A1C reduction with less hypoglycemia and weight loss 1