Can Actrapid (Human Insulin) Be Given to a Patient with Hyperglycemia?
Yes, Actrapid (human regular insulin) is appropriate and effective for treating hyperglycemia, though the specific regimen depends on the clinical context—whether the patient is critically ill, hospitalized non-critically ill, or outpatient, and whether they have type 1 or type 2 diabetes.
Critical Care Setting (ICU/DKA)
For critically ill patients with severe hyperglycemia or diabetic ketoacidosis, continuous intravenous regular insulin (such as Actrapid) at 0.1 units/kg/hour is the standard of care 1. This approach allows for precise titration and rapid adjustment based on frequent glucose monitoring 1. The target glucose range in critically ill patients should be 140-180 mg/dL (7.8-10.0 mmol/L), as more aggressive targets increase hypoglycemia risk without additional benefit 1.
- Fluid resuscitation with isotonic saline at 15-20 mL/kg/hour must precede or accompany insulin therapy to restore circulatory volume and tissue perfusion 1, 2
- Monitor potassium every 2-4 hours and replace when levels fall below 5.2 mEq/L (assuming adequate urine output), as insulin drives potassium intracellularly and can precipitate dangerous hypokalemia 1, 3
- When transitioning from IV to subcutaneous insulin, administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping the IV infusion to prevent rebound hyperglycemia and DKA recurrence 1, 2
Non-Critically Ill Hospitalized Patients
For hospitalized patients eating regular meals with moderate to severe hyperglycemia, a basal-bolus regimen using subcutaneous Actrapid before meals is superior to sliding scale insulin monotherapy 1. The basal-bolus approach reduces postoperative complications including wound infection, pneumonia, bacteremia, and acute renal failure 1.
Initial Dosing Algorithm:
- For insulin-naive patients or those on low-dose insulin: start with 0.3-0.5 units/kg/day total daily dose, divided as 50% basal insulin and 50% prandial insulin (Actrapid) split among three meals 1, 4
- For patients with blood glucose 201-300 mg/dL: use 0.2-0.3 units/kg/day 4
- For patients with blood glucose >300 mg/dL: reduce home dose by 20% or start 0.3 units/kg/day as total daily dose 4
- For high-risk patients (elderly >65 years, renal failure, poor oral intake): use lower doses of 0.1-0.25 units/kg/day 1, 4
Titration Protocol:
- Increase prandial Actrapid by 1-2 units if postprandial glucose consistently exceeds 180 mg/dL 1, 4
- Check point-of-care glucose before each meal and at bedtime 4
- Target glucose range: 140-180 mg/dL for non-critically ill hospitalized patients 4
Critical Pitfall to Avoid:
Never use sliding scale insulin (correction doses only) as monotherapy—this approach is explicitly condemned by all major diabetes guidelines 1, 4. Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1. Actrapid should be given as scheduled doses before meals with correction doses as an adjunct only 1.
Outpatient/Ambulatory Setting
For outpatient management of type 2 diabetes with hyperglycemia, long-acting basal insulin (glargine, detemir, or degludec) is preferred over regular insulin like Actrapid for basal coverage 4. However, Actrapid can be used as prandial insulin when basal insulin alone is insufficient.
When to Add Prandial Actrapid:
- When basal insulin has been optimized (fasting glucose 80-130 mg/dL) but HbA1c remains above target after 3-6 months 4
- When basal insulin dose approaches 0.5-1.0 units/kg/day without achieving HbA1c goals 4
- Start with 4 units of Actrapid before the largest meal or 10% of the basal dose 4
- Titrate by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 4
Critical Threshold Warning:
When basal insulin exceeds 0.5 units/kg/day, adding prandial insulin like Actrapid is more appropriate than continuing to escalate basal insulin alone 4. Continuing to increase basal insulin beyond this threshold leads to "overbasalization"—a dangerous pattern characterized by hypoglycemia, high glucose variability, and bedtime-to-morning glucose differential ≥50 mg/dL 4.
Special Clinical Situations
Glucocorticoid-Induced Hyperglycemia:
For patients on once- or twice-daily steroids, NPH insulin is the standard approach, but Actrapid can be used for prandial coverage 1. Glucocorticoids cause disproportionate daytime hyperglycemia, requiring increased prandial and correction insulin by 40-60% or more in addition to basal insulin 4.
Perioperative Care:
- Withhold any oral glucose-lowering agents the morning of surgery 1
- Give half of NPH dose or 75-80% doses of long-acting analog 1
- Monitor blood glucose at least every 2-4 hours while patient is taking nothing by mouth and dose with short- or rapid-acting insulin (like Actrapid) as needed 1
- Target range: 80-180 mg/dL (4.4-10.0 mmol/L) 1
Renal Impairment:
For patients with CKD Stage 5, reduce total daily insulin dose by 50% for type 2 diabetes and 35-40% for type 1 diabetes 4. Insulin clearance decreases with declining kidney function, requiring closer monitoring for hypoglycemia 4.
Type 1 Diabetes Considerations
For type 1 diabetes, Actrapid can be used as prandial insulin, but rapid-acting analogs (lispro, aspart, glulisine) provide better postprandial glucose control 4. Total daily insulin requirements typically range from 0.4-1.0 units/kg/day, with approximately 50% as basal insulin and 50% as prandial insulin 4.
- Actrapid should be administered 30 minutes before meals (unlike rapid-acting analogs which are given 0-15 minutes before meals) 4
- Never use sliding scale insulin alone in type 1 diabetes—these patients require scheduled basal-bolus therapy 1