diabetes - insulin initiation - insulin initiation ... · pdf filethese guidelines are...

these guidelines are designed for use by those trained and competent in insulin initiation

diabetes - insulin initiation - University Hospitals of LeicesterNHS Trust

Working in partnership with PCTs across Leicestershire and Rutland

Date of preparation: May 2008. For review: May 2010.


diabetes - insulin initiation - background information (1) University Hospitals of LeicesterNHS Trust


indications for insulin:•NewlyDiagnosedType1Diabetes

•Allpreviousattemptstoachievedesiredtargethavefailedi.e.lifestylemeasures,maximumoraltherapy

•PersistentfailuretoachievedesiredHbA1c

•Patientsymptomatic,i.e.weightloss,lethargy

• Type2Diabeteswhereearlyinsulinisindicated(seeGlycaemicManagementGuidelines)

•SteroidinducedDiabetes

•GestationalDiabetes

•Postacutemyocardialinfarction

• Intolerancetooralagents

•Moresuitabletopatientslifestyle

•Acuteneuropathiessuchasproximalamytrophy

logistics for insulin initiation:• Identifydedicatedtimebycompetenthealthcare

professional for initiation and follow up.

•OnetooneconsultationsorGroupsessions.

• Identifyandagreethemostappropriateinsulinregimes(seeInsulinInititiation-IndicationsforInsulinandPotentialRegimens).

•Makesureappropriateequipmentandeducationalmaterialisavailable.

• Identifyappropriateenvironment.

•Provideongoingsupportandcontactdetails.

principles of good practice:• InType2Diabetestheissueofinsulinshouldbediscussedearlyoninthediagnosis.

• InType2Diabetesthinkaboutinsulinearly,i.e.whenHbA1cisprogressivelyrisingandisconsistentlyabove>7.4%andmaximumtoleratedoraltherapyandlifestylechangesareinplace.

• InType1Diabetesstartinsulinwithin24hours.

• Thewayinwhichthesubjectisapproachedshouldbesensitivetothepersonsneeds.

•Thedecisiontostartinsulinshouldbedoneinagreementandpartnershipandthechoiceofregimetailoredtotheindividual’s needs.

• Insulininitiationshouldbepartofastructuredcareplanandeducationalprogramme.

•Thepersonshouldagreetoandunderstandthebenefitsofinsulin;inadditiontheyshouldalsounderstandtheimplicationofinsulin(seeSupportingInformation(1)and(2)).

•Thepersoninitiatinginsulinshouldbetrainedandcompetent.

• InGestationalDiabetesinsulinshouldbemanagedbythesecondarycareteam.(SeeReferralCriteriatoSpecialistServices.)tel: lri - 0116 258 6403: lgh - 0116 258 4855.

•Thereshouldbeprovisionforadequatestructuredfollowup.

•Accesstoappropriatedietaryadviceisessential.

•Animalinsulinsarenotrecommendedfornewinsulinstarts.

key principles• ManypatientswithType2diabeteswillrequireinsulin

therapy.IntheUKPDSover50%ofpatientsby6yearsrequiredadditionalinsulintherapy.

• InitiationofinsulintherapyinType2diabetesstillremainsmoreofanartthanascienceatthepresenttime,andthisareacreatesmuchconfusion.

• ItisimpossibletoproducesimpleguidelinesapplicableforeverypatientwithType2diabetesforinsulininitiation.Thereis no clear evidence to suggest that any particular approach hassignificantadvantagesoverandaboveanalternativeapproach.

• InnormalandoverweightpatientswithType2diabetes,Metformintherapyshouldbecontinuedatthemaximumtolerateddose,aslongasthereisnocontra-indication,e.g.eGFR<30ml/min(donotinitiateifeGFR<45ml/min),unstableheartfailure.(ItisimportanttocheckthatthepersonhasnosymptomsofintoleranceofMetformintherapy.)

potential barriers to starting insulin:•Occupationalissues

(SeeInsulinInitiation-SupportingInformation1).

•Fearofinjections

•Fearofhypoglycaemia

•Fearofweightgain

SupportfromDSNsinthecommunityandUHLisavailableonrequest(seeDiabetesGuidelines).

Accreditedinsulinmanagementtrainingisavailablelocally.Visit www.leicestershirediabetes.org.uk

for more information






diabetes - insulin initiation - background information (2)Working in partnership with PCTs across Leicestershire and Rutland

Insu

lina

ctiv

ity0 2 4 6 8 10 12 14 16 18 20 22 24

Soluble Human Insulin: Actrapid, Humulin S

Onset: 30minsPeak: 2-4hoursDuration: 6-8hours

Insu

lina

ctiv

ity

0 2 4 6 8 10 12 14 16 18 20 22 24

Rapid Acting Insulin Analogue: Novorapid Aspart, Humalog Lispro, Apidra

Onset: 0-15minsPeak: 1-2hoursDuration: 3-5hours

Insu

lina

ctiv

ity

0 2 4 6 8 10 12 14 16 18 20 22 24

Intermediate Human Isophane Insulin’s: Insulatard, Humulin I

Onset: -Peak: 4-8hoursDuration: 14-16hours

Insu

lina

ctiv

ity

0 2 4 6 8 10 12 14 16 18 20 22 24

Long Acting Basal Analogues: Glargine (Lantus), Detemir (Levemir)

Onset: ~2hoursPeak: NoneDuration: 18-24hours

Insu

lina

ctiv

ity

0 2 4 6 8 10 12 14 16 18 20 22 24

Pre-mixed Human Soluble/Isophane: Mixtard 30, Humulin M3 etc

Onset: SeeabovePeak: SeeaboveDuration: SeeaboveMixtard30,M3refersto%of solubleinsulinie.30%Soluble 70%Isophane

Insu

lina

ctiv

ity

0 2 4 6 8 10 12 14 16 18 20 22 24

Pre-mixed Analogues/Isophane: Novo Mix 30, Humalog Mix50, Mix25

Onset: SeeabovePeak: SeeaboveDuration: SeeaboveNovoMix30,HumalogMix50/Mix25refersto%ofrapidacting analogue insulin

oVerView of insulin and actions

animal insulinsSomepatientsonanimalinsulinsareadequatelycontrolledanddonotrequireachangeininsulinregimen.

Indications for changing to Human or Analogue Insulin regime:

•Poororerraticcontrol

•Problemswithhypoglycaemia

•Patientchoice

•Failuretoreachglucosetargets

•Useofdevices

•Problemsatinjectionsites

Whenchangingfromanimaltoanalternativeinsulina20%reductionindoseisrecommended,initiallytheywillrequireweeklyreviewofmonitoring.Maywishtoseek specialist advice.

NB:Rarely,somepatientswhopreviouslychangedfromanimaltohumaninsulinmayexperiencedifficultieswithhypoglycaemiaandprefertorevertbacktoanimalinsulin.ThisshouldbediscussedwiththeSpecialistTeamonanindividualbasis.

• InrelationtocombinationwithinsulininType2Diabetesonly: Biguanides: Metformin.

Evidence support combination with insulin due to benefits in weight management, glycaemic control and CHD risk.

• Sulphonylureas,InsulinSecretagogues,PrandialGlucoseRegulators(Nateglinide,Repaglinide) Generally are discontinued when commencing insulin. Evidence supports some combinations (See Insulin Initiation - Detailed Guide). Usually continue if using once daily basal analogue and regularly review dose.

• Glitazones:Pioglitazone,Rosiglitazone. Usually discontinue when insulin commenced. Now licensed for use with insulin in specific circumstances - discuss with specialist team.

• Acarbose:In our practice we do not use in combination with insulin although there is some evidence to support this.

oVerView of the use of oral hypoglycaemic agents in combination with insulin:(fordetaileddescriptionseeDiabetesManagement-OralAgents).

University Hospitals of LeicesterNHS Trust




diabetes - insulin initiation - supporting information (1)

hypoglycaemia

driVing

monitoring

employment

weight management

healthy eating

coping with illness

hypoglycaemiaKeypointstoconsider:

•Peopleworryaboutit.

•Needtoidentifysymptoms,potentialcausesandtreatment.

•Prevention.

•Whentoseekhelp.

driVingKeypointstoconsider:

•Riskofhypoglycaemia.

•Lossoflivelihood.

• ImplicationsforinsuranceandDVLA.

Ensure individual understands their responsibilitiesintermsofsafety.See Diabetes UK information.

monitoring•Selfbloodglucosemonitoring(SBGM)usually

recommended.

•ThoseunabletoSBGMmayfindurinetestinghelpfulandmayrequiremorefrequentHbAICmeasurement.Seemonitoringglycaemiccontrolguidelines.

employment•DiabetesiscoveredbytheDisabilityDiscrimination

Act1995.

•Certainoccupationsarelimitedforthoseoninsulin,e.g.EmergencyServices,Forces.ContactDiabetesUKCarelineformoredetails.

•Shiftpatternsandactivitylevelswillneedtobeconsidered.

FurtherinformationisavailablefromDiabetesUKCareline: 0207 4241000.

coping with illness• Insulindosesmayneedadjustingduringillness.

•Patientsmayrequireadditionalsupport.

•Morefrequentmonitoringmayberequired.

•GenerallyinsulinshouldneverbestoppedinType2Diabetes.

type 1 diabetes• Insulinshouldneverbestoppedasthereisarisk

of ketoacidosis.

•Patientsshouldtesturineorbloodforketonestoidentify risk of ketoacidosis.

•Theymayrequirespecialistadvice.

weight managementGenerallypeoplegainweightoninsulintreatmentmainlyduetoimprovedglycaemiccontrol. Consider:

•Earlydiscussionofappropriateweightforindividual.

•Discussionofweightmanagementstrategies.

•Unexplainedweightlossorgain,considerreferralfor specialist advice.

healthy eating•Theneedforahealthydietisnotaffectedby

insulin initiation.

•Additionalsnacksarenotautomaticallyrequiredandshouldbetailoredtotheindividualsneeds.

•Caremustbetakentoensurethatadvicegivenaboutchangingeatinghabitsisnotdetrimentaltotheindividual’sweightmanagementgoals.



diabetes - insulin initiation -Working in partnership with PCTs across Leicestershire and Rutland


diabetes - insulin initiation - supporting information (2)

exercise

alcohol

traVel

special occasions and cultural issues

on going care

help and support

exercise•Mostpeoplewouldbenefitfromincreasing

physical activity levels.

•Caremustbetakentoavoidhypoglycaemia.

•Someinsulinregimesmaybemoresuitableforpeople with active or varied lifestyles.

•Mostsportsarepossibleforpeopleoninsulin,howeverthereareafewexceptionseg.deepseadiving,free-fallparachuting.

Alltypesofactivityhaveaneffectonglycaemiccontrol.

alcohol•Governmentguidelinesonalcoholintakearethe

sameforpeopleoninsulin.

•Alcoholbeverageshavedifferenteffectsonbloodglucose levels.

•Theriskofdelayedhypoglycaemianeedstobediscussed.

•Wherealcoholicintakeexceedsrecommendedlevels,peopleneedappropriateadvicetominimiserisks.

traVel• Insulindoesnotrestricttravelopportunities,

butplanningisrequired.

•Considerdestination,climate,illness,changeinactivity,modeoftravel,availabilityandstorageofsupplies.

•Carryadequateidentification.Asupportingletterfromahealthcareprofessionalonheadedpapermaybenecessary.

help and supportSupporting literature available from:LeicestershireDiabetesWebsite-forhealthcareprofessionalsandpeoplewithdiabetes. www.leicestershirediabetes.org.uk

DiabetesUK tel: 0207 424 1000 Websitewww.diabetes.org.uk

NovoCareCustomerCareCentre tel: 0845 600 5055 Website:www.novonordisk.co.uk

LillyDiabetesCareUK tel: 01256 315000 Website:www.lilly.co.uk

Sanofi-AventisCustomerServices tel: 0845 606 6887

special occasions and cultural issues•Patientsmayneedadditionaladvicetomanage

thesesituations,especiallyaroundfeastingandfasting

•Culturalawarenessandsensitivityareessential.

•Participationineventsdoesnothavetoberestricted.

Furtherinformationisavailablefrom: •www.leicestershirediabetes.org.uk •DiabetesUKWebsite-www.diabetes.org.uk •Servier-01753662744.

ongoing care•Regularfollowupisrequiredtailoredandagreed

with the individual.

•Requirementsmaychangeovertime.

•Careshouldbepatientcentred.

•Educationshouldsupportselfmanagementskills.

Some health care professionals find it useful to compile a checklist to document advice given

wheninitiatingandmanaginginsulin.Anexample of one can be found on the

LeicestershireDiabeteswebsite-www.leicestershirediabetes.org.uk





diabetes - insulin administration and deVices (1)

points for considerationHavingmadethedecisiontocommenceInsulin(SeeInsulinInitiation-BackgroundInformationsheet)thefollowingpointsmayinfluencechoiceofregimeanddevices:•Dexterity•Vision•Eatingpatterns•Lifestyle•Occupation•Agreedfrequencyofinjections•Abilitytograsp

techniques

NB:Choicemaybeinfluencedbyavailableformatofinsulin,eg.10mlvialsforusewithsyringes,3mlcartridges for use with pens or preloadeddisposablepensetc.

list of leaflets aVailableLeicestershire Diabetes Websitewww.leicestershirediabetes.org.uk

Diabetes-TheWaytoGoodNutritionLeicestershireNutrition&DieteticService

UHL Diabetes Department-leaflets•LRI-0116 258 5545•LGH-0116 258 8249

Diabetes and Insulin LeafletsonallaspectsofDiabetesandInsulin

Novo Nordisk-0845 600 5055Lilly-01256 315 999Sanofi-Aventis -0845 606 6887

how to inject•DialordrawupcorrectdoseofInsulinasperchosen

device.

•RemembertoagitateInsulinifrequired.

•Chooseinjectionsite(seepicture).

•Pinchupsubcutaneousfatfor8mmandaboveneedles(nopinchuprequiredfor5mmx6mmneedles).

• Insertneedledirectlyintoraisedarea.

•DepressplungerorbuttontodeliverInsulinaspermanufacturersinstructions.

•Holdneedleinplacefor10secondsthenremoveneedlefromarea.

sharp disposalThereisnationalguidancefordisposalofsharps.Seewww.leicestershirediabetes.org.uk.Guidanceshouldinclude advice around:•Useofsafeclipdeviceasaneedleclipper.

• Issueanddisposalofsharpsboxesoralternativecontainerstomeetindividualsneeds.

•Avoidanceofdisposalofsharpsingeneralrefusetopreventneedlestickinjuriesetc.

YourPCTwillhavelocalguidelinesonsharpdisposal.

pen deVices•SpareInsulincartridges/pre-filledpen-keepinfridge.

•Pencurrentlybeingusedcanbekeptatroomtemperatureforupto1month.

syringes•SpareInsulinvialsshouldbekeptinthefridge.

•TheInsulinvialthatisincurrentusemaybekeptatroomtemperatureforupto1month,Insulinremaininginvialafterthislengthoftimeshouldbedisposedof.

points to rememberInsulinisaffectedbyextremesoftemperaturei.e.veryhotorfreezing.Avoidkeepingincontactwithdirectheatorsunlightor risk of freezing e.g. in the hold of an aircraft.

•REMEMBERthatbetweeninjectionssomeInsulinparticlesseparateandtoensurecorrectconcentration/consistencytheseInsulinsneedtobemixedbyinverting20timespriortoinjectingthem.

storage of insulin

• Injectionsitesshouldbecheckedregularly.LipohypertrophycaneffecttheabsorptionofInsulin-ifapatientstopsusinga"lumpy"injectionsitebloodglucoselevelsshouldbemonitoredcloselyasareductioninInsulinmayberequiredtoavoidhypoglycaemia.

•Buttockscanalsobeused.Armsshouldbeusedwithcaution due to rapid onset of action.

•Encouragethepracticeofrotatingplaceifinjectingwithina chosen site.

•Rotatinginjectionsitesmayresultindifferingratesofabsorptionbetweensitesandneedstobetakenintoconsideration,eg.insulinisabsorbedmorequicklyfromtheabdomenthanthethighs.

injection sites



diabetes - insulin administration and deVices (2)



Company&PenName InsulinUsed Min-Max Cartridge Reusableor On Dose Size Pre-filled Prescription

noVo nordisk Novopen3Classic AlltypesNovoNordisk 1-70units 300units(3ml) Reusable Yes insulinPenfill3mlcartridge NovopenJunior AlltypesNovoNordisk 0.5-35units 300units(3ml) Reusable Yes insulinPenfill3mlcartridge (0.5unitdosing)

Novopen3Fun AlltypesNovoNordisk 1-70units 300units(3ml) Reusable Yes insulinPenfill3mlcartridge Flexpens Detemir,Novorapid 2-70units 300units(3ml) Prefilled Yes andNovomix30 Innolet Insulatard,Mixtard30 1-50units 300units(3ml) Prefilled Yes

lilly HumapenLuxura Lilly3mlcartridges 1-60units 300units(3ml) Reusable Yes HumapenLuxuraHD Lilly3mlcartridges 0.5-30units 300units(3ml) Reusable Yes (0.5unitdosing)

Lillyprefilledpen LillyPrefilledRange 1-60units 300units(3ml) Prefilled Yes Humajectprefilledpen LillyHumajectRange 2-96units 300units(3ml) Prefilled Yes

sanofi-aVentis OptiPenPro1 InsumanRange 1-60units 300units(3ml) Prefilled Yes Opticlik LantusandApidra 1-80units 300units(3ml) Reusable Yes Optiset Lantus,Apidra&InsumanRange 1-42units 300units(3ml) Prefilled Yes Solostar LantusandApidra 1-80units 300units(3ml) Prefilled Yes AventisOptiset InsumanRange&Lantus 2-40units 300units(3ml) Prefilled Yes Autopen24 LantusandApidra 2-40units 300units(3ml) Reusable Yes

owen mumford Autopen3ml Alltypesof3mlcartridges 1-21units 300units(3ml) Reusable Yes exceptNovoNordisk3ml Autopen3ml Alltypesof3mlcartridges 2-42units 300units(3ml) Reusable Yes exceptNovoNordisk3ml

guide to insulin penspen needles

syringes

ThefollowingtablehighlightspenneedlescurrentlyavailableintheUK.Therearefivedifferentneedlelengthsavailable-5mm,6mm,8mm,12mm,and12.7mm-andfourdifferentalternativegaugesorwidths-28G,29G,30G,and31G.AllneedlesshouldfitallInsulinpens(excepttheOptiPenProinsulinpenfromAventis,whichcanonlyusethePenfineneedlefromDisetronic).

Therecommendationisthatanewneedleisusedforeachinjection.

Useafreshsyringeforeachinjection.

Product Name Manufacturer Length Width

BD Microfine + BectonDickinson 12.7mm 29G 8mm 31G 5mm 31G

Novofine NovoNordisk 12mm 28G 8mm 30G 6mm 31G

Unifine Pentips OwenMumford 6mm 30G 8mm 30G 12mm 29G Penfine Disetronic 6mm 31G 8mm 31G 12mm 29G

Name Manufacturer Syringe NeedleLength Capacity Available

BD Microfine + BectonDickinson 0.3ml 8mm 0.5ml 8mm/12.7mm 1.0ml 8mm/12.7mm

Choiceofneedlemanufacturerwilldependprimarilyonpatientchoice.ChoiceofneedlelengthwillbedeterminedbybothpatientchoiceandBMI,butmostpatientswillonlyrequire5mm-8mmneedles.Althoughthereisnoevidenceofneedlelengthrelatingtopain,thereispsychologicalbenefittotheshorterneedles.Thereisariskthat12mm-12.7mmneedlesmayresultininsulinbeinginjectedintramuscularly,especiallyifthepatientisthinanddoesnot“pinchup”subcutaneoustissuebeforeinjecting.





diabetes - potential regimens (type 2 diabetes)

Mostcommonlyusedinsulinregimens Metformincanbecontinuedincombinationwithallinsulinregimes,asoutlinedhere,inpatientswithType2Diabetes:

1. twice daily pre-mixed insulin which includes conventional mixturesofshort-actingandisophaneinsulin,e.g.HumanMixtard.Themostcommonlyusedratiois30/70.Insulinanaloguemixturesareavailablewithapercentageof short-actinginsulinof25%,30%and50%.Short-acting insulin analogue mixtures such as Novomix 30 and HumalogMix25andMix50,arenowavailableandmayhave particular advantages in terms of patient convenience(noneedtowaitbeforeeating)andcontrolof post-meal glucose.

2. once-daily basal insulinincombinationwithoralhypoglycaemicagent,toincludeeitherasulphonylureaoraprandialglucoseregulatorwithMetforminiftolerated.Evidencesuggests that conventional isophane insulin when used in this regimeisbestadministeredeitherintheeveningorbeforebed.Basalinsulinanaloguesincludinginsulinglargineanddetemirhavebeensuggestedforuseonceadayincombinationwithoralagentsastheyhaveparticularadvantagesintermsofnocturnalhypoglycaemia.

3. twice-daily isophane insulinusedasbasalinsulintherapy.Thisapproachislikelytobesupersededbytheuseofonce-dailybasalinsulinanaloguesasdatasuggeststheyareaseffectiveintermsofA1cloweringandhaveareducedriskofhypoglycaemia.Otherfactorssuchascostsandchoiceofinsulindevicemaymeanthecontinueduseoftwice-dailyisophaneinsulin(i.e.HumanInsulatardorHumulinI)insomepatients.

4. formal basal bolus regime(i.e.fourinjectionsofinsulinperday).Short-actinginsulinorshort-actinganaloguesbeforeeachofthemainmealsandbasalinsulin(eitheronceortwicedailyisophaneinsulinoroncedailylong-actinginsulinanalogue,i.e.insulinglargineordetemir).OftenusedinpatientswithType1diabetes.RarelythefirstchoiceinpatientswithType2diabetes.

factors influencing choice of regimen• Isthepatient’slifestylevariable?(e.g.dotheyworkshifts,do

anysportoractivity,haveajobwhichrequireslotsoftravellingandirregulareatingpatterns?)

•Hasthepersongotspecialneedsorneedassistancewithadministrationofinsulin?(e.g.problemswithdexterity,problemswitheyesight,cognitivedysfunction?)

• Isweightanissue?• Isthenumberofinjectionsperdayanissue?• Isthispersonatparticularriskofhypoglycaemia,orcould

hypoglycaemiacauseparticularproblems(e.g.anelderlypersonlivingaloneorculturalreasonssuchasfasting?)

•Wouldamovetoinsulintherapyparticularlyaffecttheperson’squalityoflifeoroccupationalchoices(e.g.aretheyataxidriver,orholdaHGVlicence?)

•Arethereanyspecificculturalneedsorculturalreasonswhichwouldaffecttheirperceptionsofinsulintherapy?

Anappropriateinsulinregimeisusuallyrequiredtoaddressbothbasal,i.efastingandpre-prandialglucoselevelsandpost-prandial(post-meal)excursions.Atraditionalisophane(mediumacting)insulingiventwicedailysuchasHumulinIandHumanInsulatardaddressesbasalhyperglycaemia.However,thelong-actinginsulinanaloguessuchasinsulinglargineandinsulindetemirwhicharebecomingmorepopular.Theyhavetheadvantageofgreaterpredictability,potentiallylessweightgain,andlowerriskofhypoglycaemia,particularlyatnight.

Addresspost-mealglucoseexcursionswiththeuseoftheshort-actinginsulins,eitherusedaloneorincombinationasamixedinsulin.Thedisadvantagesarethatsomehavetobeinjected20/30minutesbeforeameal.Patientsneedtosnackbetweenmealsandthereisariskofhypoglycaemia.Short-actinginsulinanaloguessuchasNovorapid(aspart)andHumalog(lispro)andApidra(Glulisine)haveadvantagesintermsofconvenience,canbeinjectedwith,orindeed,aftermeals,arebetteratcontrollingpost-prandialglucosewithlessneedforsnacks,andhavealowerriskofhypoglycaemia.

targets of therapy• Patientsneedtohavetargetsindividualised.

• OptimumHbA1ctargetshouldbeinlinewithNICEandevidencebase.

• PatientswithType2diabetesshouldbe<7%(6.5%inthoseatparticularriskofcardiovasculardisease).

• Aimforapre-breakfastorfastingglucoselevelof<5.5mmol/l.

• Pre-prandiallevelsatothertimesofthedayat<6mmol/l.

• Post-prandial(i.e.2hoursafteramainmeal)<8mmol/l.

• Post-prandialglucosemonitoringmaynotbeappropriatefor all patients.

titrating doses - key principles• BloodglucosetargetsshouldbeagreedbetweentheHCP

and the patient.• Donotadjustthedoseinresponsetoindividualblood

glucosereadings.Trytolookforpatternsandestablishtheoverall picture.

• Usethemonitoringdiarytoestablishifpatternsexistatdifferenttimesoftheday.

• Takeintoaccountanycommentsdiscussedorrecordedinthemonitoringdiary.Aretheyrelatedtothebloodglucosereadings,eg.eatingpatterns,changesinactivity.

• Viewthebloodglucoseresultsinrelationtothetypeofinsulinandtimingofinjections.

• Wherepossible,decisionre:titratingthedosesshouldbemadebythepatientorinpartnershipwiththeHCP.

• Istheproblemdoserelatedordoesitindicatethattheregimenisnotmeetingthatperson’sneeds?

• Generally,increasesaremadein10%increments• Preventionofhypoglycaemiatakesprecedenceand

generallywherenoothercausecanbefounda20%reductionininsulindoseisrequiredwithcarefulmonitoringand follow up.

background information






adVantages • Thisregimeisrelativelyeasytoteachandsimpleforthe

patient to understand.• Ithaspotentialforbetterpost-prandialglucosecontrol.

disadVantages

MaybemoreeffectiveinloweringHbA1cthanbasalinsulinalone but…• Thereislessflexibility(i.e.unabletoadjusttheshortorbasal

componentofinsulinindependently).

• Patientsmaynotachieveoptimalglycaemiccontrol.

• Timedelayofinjectionwithconventionalmixture(needtoinject20-30minutesbeforeameal).

• Theneedforsnacksbetweenmeals(withthenewanaloguemixturethedelayininjectiontimeisnotrequiredandtheneedforsnacksmaybereduced).

• Titrationmaygetcomplicatedanddifficulttoteach.

• Potentialriskofhypoglycaemiaandweightgain.(Early data from the 4T study).

TWICeDAILYPRe-MIxeDINSULIN Either conventional short-acting and isophane insulin, e.g. Mixtard 30/70, Humulin M3 or analogue mixed insulin, e.g. Novomix 30 or Humalog Mix25.Theadventofshort-actinginsulinanaloguemixturesmeansthatthisregimeisnowavailablewithashortactinginsulinanalogue,eitherasNovomix30with30%short-actinginsulinanalogueorHumalogMix25(25%shortactinginsulinanalogue).

Theparticularchoiceofwhichpre-mixedinsulinisusedmaybeinfluencedby:

• choiceofinsulininjectiondevice• perceivedconvenienceforpatients• potentialforweightgainandriskofhypoglycaemia.

SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYBefore breakfast and before evening meal: Use10unitsb.d.Consideralowerstartingdoseinsomecircumstances,eg.frail,elderlyor‘slim’patients. Remembertheywillneedregularreviewfortitrationofdoses.

TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.• Morningdoseofinsulintitratedagainstpre-lunchandpre-

eveningmealbloodglucosetests:suggest2unitincrementsincreasewithatargetglucoseof<6beforelunchandbeforeeveningmeal.

• Eveningdosetitratedagainstpre-bedandpre-breakfasttest.Titratetotrytoachieveabeforebreakfastbloodglucoseof5.5-6.Bewareofbeforebedtestsof<6:aimforabeforebedtestbetween6and8.Watchcarefullyfortheriskofnocturnalhypoglycaemia.

• InpatientswithType2DiabetesandBMI>19,Metformintherapyshouldbecontinuedatthemaximumtolerateddose,aslongasthereisnocontra-indication,e.g.creatinine>130,unstableheartfailure.(ItisimportanttocheckthatthepersonhasnosymptomsofintoleranceofMetformintherapy.)

INDICATIONfORCHANGeOfReGIMeNIfglycaemictargetsarenotreachedaftertitration,changemayberequired.forexample:-• Ifcontrolremainssuboptimal.

• Hypoglycaemia(particularlyinthenight).

• ExcessiveweightgaindespitecontinuedMetformin.

• Patient’spreferenceorlackofflexibilitywiththeregimeforpatientstoundertakelifestyle(e.g.erraticjoborexercise).

• Ifbeforetheeveningmealdosebloodglucoseremainshighbutfurthertitrationcausesmid-morninghypoglycaemia.Thereare several options:

• Continuepremixedinsulinandaddinshortactinginsulinatlunchtimeifhighbloodglucosebeforeeveningmeal.

• Sticktopre-mixtwiceadaybutchangetheproportionsofinsulin(e.g.HumalogMix50).

Thereisnowalimitedchoicefollowingthediscontinuationofsomepre-mixedinsulins.ThosestillavailableareNovomix30,HumalogMix25,HumalogMix50andMixtard30andHumulinM3.

• Movetoabasalbolusregime(seeappropriatesheet).

• Offerthepatientfreemixingofinsulin.However,thedisadvantageofthisisthatitiscomplicatedtoexplainandteachtopatients,accuracyisanissue,andthepatientswouldneedtomoveawayfromapendevicebacktoaneedleandsyringe.

Theapproachtoinsulintherapyiscontinuouslychanging.Recentevidencesuggestingamoreproactiveandcalculateddoseandtitrationmaybemoreappropriateforthoseexperiencedininsulinmanagement.ToadoptthisapproachseetheLeicestershireDiabeteswebsite:www.leicestershirediabetes.org.uk.

an accredited masters level training module on insulin initiation and management is available. see www.leicestershirediabetes.org.uk for details

adVanced approach to insulin initiation

twice daily premixed insulin








SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYUse10unitsoncedailyusuallygivenatbedtime(9-10pm)orwitheveningmealforIsophane.

Long-actinganaloguesmaybegivenmorningoreveningatatimesuitableforthepatient,butitmustbeconsistentfromdaytoday.

TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.

Regime for basal insulin analogue is :• Fastingplasmaglucoselevel5.5mmol/l-6.0mmol/l,increase

insulinglargineordetemirdose2unitsevery3daysuntilpre-breakfastbloodglucose≤5.5mmol/landthereisnonocturnalhypoglycaemia.

Althoughbasalanaloguesaredesignedtoworkthroughouta24hourperiod,thismayvarybetween16-24hours.Iftheinsulinistakeninthemorningconsiderthatraisedfastingglucoselevelsmaybeduetotheinsulinrunningoutratherthaninadequatedose,andtwicedailyinsulinmayberequired.

Remember:• Usethreeconsecutiveself-monitoredfastingglucoselevel

(beforebreakfast)toadjustdoses.

• Wait3-4daysbetweenadjustments.

• Reducethedoseiffastingglucosefallsbelow4oranunexplainedhypoglycaemicepisodewasexperienced.Theamountofdecreaseneedstobeatleast2-4unitsor10%,whichever is greater.

INDICATIONfORCHANGeOfReGIMeN• Fastingglucoselevelsareattargetbutifpost-prandialglucose

levelsremainhighdespitemaximumtoleratedoralagents,itmaybeappropriatetostoptheseandchangetoaformalbasalbolusregimen.Seerelevantguidance.

• Controlremainssuboptimal.

• Recurrentunresolvedhypoglycaemia.

• Patient’spreferenceorneedforgreaterflexibilitywithregardtolifestyle(eg.exercise,employment).

Considertwicedailypre-mixedinsulinorformalbasalbolusregimen.

ONCeDAILYbASALINSULIN Either long-acting insulin analogue (Glargine (Lantus), Detemir (Levemir)) or isophane insulin (Humulin I, Insulatard)withcontinuedoralhypoglycaemicagents.• Onceadayinsulinanalogues(Glargine(Lantus),Detemir

(Levemir))aredesignedtoworkthroughouta24hourperiodwitha‘peakless’action.

• Pre-breakfast(fasting)bloodsugarsareagoodindicatoroftheireffectiveness,butrememberthatitinsomeindividualstheydonotlastfor24hoursandmayberequiredtwicedaily.(BDdosingmorelikelywithDetemir).30%ofpatientsinthe4Tstudyrequiredaseconddoseofinsulindetemir.

• The‘peakless’insulinsarenoteffectiveinloweringmeal-time(prandial)risesinbloodsugar.Ifthiscannotbeadequatelycontrolledwithlong-actinginsulinandoralhypoglycaemicagents,shortactinginsulinwillneedtobeadded.

• Basalinsulinanaloguesshouldnotbemixedinsyringeswith other insulins.

• Shouldbeinjectedatapproximatelythesametimeeveryday(2hourwindow).

adVantages • The4Tstudyindicatesthatinpatientswithtype2diabetes

andabaselineHbA1c<8.5%aoncedailybasalinsulinregimeniseffectiveandsafewithalowerriskofhypoglycaemiaandweightgain.

• Itissimpleandeasyforearlyfacilitationtoinsulin.• Potentiallylessweightgain.• Potentialforlessriskofhypoglycaemia.• Relativelyeasyregimeforhealthcareprofessionalstosupport.• Usefulforsymptomreliefiftightcontrolisnotamajorissue.

disadVantages

• Patientsmaynotachieveoptimalcontrol.• Theregimemaynotofferoptimumcontrolofpost-meal(post-

prandial)hyperglycaemia.



CHOICeOfORALHYPOGLYCAeMICAGeNT Yourchoiceoforalhypoglycaemicagent,particularlytheinsulinsecretagogue,maybeimportantifchoosingthisregimen.AlwayscontinueMetformininthenormalandoverweightpatientsatthecurrentdoseunlesscontra-indicatedornottolerated.AlwayscheckforsymptomsofMetforminintoleranceinpatients.

• Continueprevioussulphonylureaatunchangeddose.Foreaseoftherapyonemaywishtoconsiderachangetoonce-dailyGlimepiridetitrateduptoadoseof4-6mgorGliclazideMRThisisagoodchoiceifeaseofadministrationisanissue.

Theapproachtoinsulintherapyiscontinuouslychanging.Recentevidencesuggestingamoreproactiveandcalculateddoseandtitrationmaybemoreappropriateforthoseexperiencedininsulinmanagement.ToadoptthisapproachseetheLeicestershireDiabeteswebsite:www.leicestershirediabetes.org.uk



basal insulin with oral hypoglycaemic agents






SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYTostart10unitsb.dofisophaneinsulin,i.e.humanInsulatardorHumulinI.Choiceofdevicemayinfluencethepatient’schoice.

TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.

Totitrateup2unitsperdayuntilthepatientison20unitsperdaywhenthe10%ruleisapplied.Adjusttheinsulinupevery3-4daysinrelationtohomemonitoringresults,e.g.Pre-eveningmealresultsrelatetomorninginsulin,pre-breakfastresultsrelatetoeveninginsulin.

INDICATIONfORCHANGeOfReGIMeN• Hypoglycaemia.

• Suboptimalcontrol.

• Fluctuationsinbloodglucoselevelsinrelationtoinsulinaction.

TWICe-DAILYISOPHANeINSULIN InpeoplewithType2DiabetesandbMI≥19• Metformintherapyshouldbecontinuedatthemaximum

tolerabledoseaslongasthereisnocontra-indication,eg.creatinine>130,unstableheartfailure.Itisimportanttocheckthatthepersonhasnosymptomsofintoleranceofmetformintherapy.

Keypoint: With the advent of the basal insulin analogues and the advantagesintermsofweightgain,predictabilityandreducednocturnalhypoglycaemia.Itisnotlikelythatthisregimewillremainapopularchoice.SeePotentialRegimens-basalInsulinwithOralHypoglycaemicAgentsorTwiceDailyPre-mixedInsulin.

adVantages • Relativelyeasy.

• Lessriskofhypoglycaemia.

• Particularlysuitablewhensomebodyhasaproblemwithhighpre-prandialglucoselevels.

disadVantages

• Difficulttoobtainoptimalcontrol.

• Difficulttomanagepost-prandialhyperglycaemia.

• Doesnotparticularlyallowflexibility.

• Newlongactinginsulinanalogueshaveaddedbenefits.

• Theevidencebaseischangingforotherinsulinregimens.

twice daily isophane








SIMPLeAPPROACHTOTRANSfeRTObASALbOLUSINSULINTHeRAPY• Ifalreadytakingonceortwicedailybasalinsulin-continuethisandsimplyaddquickactinginsulinorquickactinganaloguebefore

eachmainmeal.• Iftakingpremixedinsulin,calculatehowthepresentdoseofpre-mixedinsulinisdividedintoshortandlongacting,andusethisto

influence decision.

TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.Adjustthebasalinsulin(longacting)toachievesatisfactorypre-breakfastbloodglucoselevels,waiting3-4daysbetweenadjustments.

Althoughbasalanaloguesaredesignedtoworkthroughouta24hourperiod,thismayvarybetween16-24hours.Iftheinsulinistakeninthemorningconsiderthatraisedfastingglucoselevelsmaybeduetotheinsulinrunningoutratherthaninadequatedose,andtwicedailyinsulinmayberequired.

Reducethedoseifbloodsugaristoolowduringthenightorpre-breakfastresultis≤5mmol/lonmorethanoneoccasionor<4.5mmol/lononeoccasion.

Adjusttheshortactinginsulintoachievesatisfactorybloodglucoselevels2hoursafterthemealorbeforethenextmeal.

INDICATIONfORCHANGeOfReGIMeN• Difficultyingivingmultipleinjections.• Changetoamoreregimentedlifestyle,wherepatientdoesnot

requiretheflexibility.


bASALbOLUSReGIMe• Atleastfourinjectionsofinsulinperday.

• Shortactingorshortactinginsulinanaloguesbeforeeachofthemainmeals,andbasalinsulin(eitheronceortwicedailyisophaneorlongactinginsulinanalogues,eg.glargineordetemir).

• OftenusedinpeoplewithType1Diabetes.

• RarelyafirstchoiceinpatientswithType2Diabetes.

• Usefulforpatientswhorequireflexibilityonadailybasis,withirregularlifestyles,variedmealtimesorirregulareatingpatterns,shiftworketc.

Anexampleofsomeoneinwhomthismaybeusefulisanactive,motivatedpersonwithanerraticlifestylewhowantstoimproveglycaemiccontrol.

adVantages • Offersoptimumflexibilityintermsofdietandactivity.

• Potentialforthelowriskofhypoglycaemia.

• Potentialforbettermetaboliccontrolifusedoptimally.

• Closelymimicsnormalinsulinphysiology.

• Potentialforthebestcontrolofbasalandpost-prandialhyperglycaemia.

• Potentialforbetterweightmanagementandlifestylechoice.

disadVantages

• Requiresmultipleinsulininjections.

• Morecomplicatedtosupportandteach.

• Requiresmoreregularglucosetesting.

• Generallymorecomplicated.



formal basal bolus regime

basalbolusregimenwithbasalanalogue (Glargine, Detemir)Addtotaldailydoseofpremixedinsulin.Usuallytakeoff20%.

Insomecircumstancesitmaynotbeappropriatetotakeoff20%,e.g.verypoorglycaemiccontrolorsymptomaticofhighbloodsugars.

Give50%asbasalinsulin.

Divideremaindertocovermealswithquickactinginsulindependantontheireatinghabits.

Eg.Mixtard30:50unitsam,50unitspm. Totaldailydose=100units-20%=80units. Give40unitsasbasalinsulinremaindergivenas12-14unitsofquickactinginsulinwitheachmealdependantoneatinghabits.

basalbolusregimenwithtwicedailyintermediateinsulin(Humulin I, Insulatard)Addtotaldailydoseofpremixedinsulin.Usuallytakeoff20%.Insomecircumstancesitmaynotbeappropriatetotakeoff20%,e.g.verypoorglycaemiccontrolorsymptomaticofhighbloodsugars.Give50%asbasalinsulindividedintotwoequaldoses.Divideremaindertocovermealswithquickactinginsulindependantontheireatinghabits.Eg.Mixtard30:50unitsam,50unitspm. Totaldailydose=100units-20%=80units. 50%ofdosedividedintotwoinjectionsofintermediateinsulin. 20unitsamand20unitspm.Remaindergivenasquickactinginsulinwith12-14unitseachmealdependantoneatinghabits.

ORchangeto:

an accredited masters level training module on insulin initiation and management is available.

see www.leicestershirediabetes.org.uk for details



premixed insulin regimen is

insulin

Blood Test Out of Target

High = increase previous evenings insulin by 2 units or 10%, whichever is greater

low = decrease previous evenings insulin by 2 units or 10%, whichever is greater

BreakfasT

insulin


High = increase breakfast insulin by 2 units or 10%, whichever is greater

low = decrease breakfast insulin by 2 units or 10%, whichever is greater

evening meal


High = increase evening meal insulin but not if blood tests at breakfast are 4-5

low = decrease evening meal insulin by 2 units or 10%, whichever is greater

BedTime


High = increase breakfast insulin by 2 units or 10%, whichever is greater

low = decrease breakfast insulin by 2 units or 10%, whichever is greater

luncH

note: exclude other causes of high or low blood glucose, such as timings of injections, injection sites, lifestyle changes etc. prior to adjusting insulin dose. • Lookfortrendsover3-4days.• Adjustinsulinevery3-4daysuntiltargetsarereachedorhypoglycaemia

becomesaproblem.

• Consider2ambloodglucosereadingifbloodsugarisintargetatbedtimebutlow,highorvariablebeforebreakfast.

• Alterinsulindoseby10%orby2-4units.• Speakwithyourdiabetesspecialistifunsure.

HOw TO adjusT insulin using BlOOd glucOse resulTs fOr a Twice daily premixed insulin

TARGeTbLOODTeSTSbefOReMeALS target ≥5 - ≤6 target >4 - ≤6 target >4 - ≤6 target >6-8

nB. yOu may need a BedTime snack On THis regimen!

points to remember

Intheabsenceof nocturnalhypoglycaemia


Oral HypOglycaemic agenTs are

lOng acTing insulin is


High = increase basal insulin by 2 units or 10%, whichever is greater

low = decrease basal insulin by 2 units or 10%, whichever is greater

BreakfasT


High = review oral medication

low = review insulin and oral medication

evening meal




BedTime




luncH

note: exclude other causes of high or low blood glucose, such as timings of injections, injection sites, lifestyle changes etc. prior to adjusting insulin dose.• Lookfortrendsover3-4days.• Adjustinsulinevery3-4daysuntiltargetsarereachedorhypoglycaemia

becomesaproblem

• Consider2ambloodglucosereadingifbloodsugarisintargetatbedtimebutlow,highorvariablebeforebreakfast.

• Alterinsulindoseby10%orby2-4units.eg.30unitswouldrequireanadjustmentof3units.

• Speakwithyourdiabetesspecialistifunsure.

HOw TO adjusT insulin using BlOOd glucOse resulTs fOr a Basal insulin regimen wiTH Oral HypOglycaemic agenTs (eg. glargine Or deTemir)

TARGeTbLOODTeSTS target >4 - ≤6

points to remember

wHen using lOng acTing analOgues:if mOsT BlOOd TesTs are HigH Over 24 HOurs increase THe dOse By 2 uniTs Or 10%, wHicHever is greaTerif mOsT BlOOd TesTs are lOw Over 24 HOurs decrease THe dOse By 2 uniTs Or 10%, wHicHever is greaTer


nB: In certain circumstances background insulin may be given at other times of day or twice daily

dependent on individual needs, such as BGM, hypoglycaemia, lifestyle issues or length of insulin

action, but must be consistent from day to day.

insulin

Background insulin aims to keep blood

glucose steady overnight and so

it may be useful to compare the bedtime

glucose result with the pre-breakfast

glucose result when adjusting the dose.

Consider that raised fasting glucose levels

may be due to the insulin running out

rather than inadequate dose,

and twice daily insulin may be required.


meal relaTed insulin is

BackgrOund insulin is


High = increase bedtime background insulin (unless hypo overnight)

low = decrease bedtime background insulin

BreakfasT


High = increase lunch related insulin

low = decrease lunch related insulin

evening meal


High = increase evening meal related insulin

low = decrease evening meal related insulin

BedTime


High = increase breakfast related insulin

low = decrease breakfast related insulin

luncH

note: exclude other causes of high or low blood glucose, such as timings of injections, injection sites, lifestyle changes etc. prior to adjusting insulin dose.• Lookfortrendsover3-4days.• Adjustinsulindosethenextdaytoimprovebloodglucosecontrol.• Changeonetypeofinsulinatatime.

• Consider2ambloodglucosereadingif bloodsugarisintargetatbedtimebut low,highorvariablebeforebreakfast

• Alterinsulindoseby10%orby2-4units. eg.30unitswouldrequireanadjustmentof3units.

• Speakwithyourhealthcareprofessionalifunsure.

target >4 - ≤6 target ≥4 - ≤6 target ≥4 - ≤6 target >6-8

points to remember

HOw TO adjusT insulin using BlOOd glucOse resulTs fOr a Basal BOlus regimen

nB: In certain circumstances background insulin may be given at other times of day or twice daily dependent on individual needs, such as BGM, hypoglycaemia, lifestyle issues or length of insulin action, but must be consistent from day to day.

meal relaTed insulin (quick or short acting)BackgrOund insulin

(see nOTe BelOw)

TARGeTbLOODTeSTSbefOReMeALS


Background insulin aims to keep blood

glucose steady overnight and so

it may be useful to compare the bedtime

glucose result with the pre-breakfast

glucose result when adjusting the dose.

Consider that raised fasting glucose levels

may be due to the insulin running out

rather than inadequate dose,

and twice daily insulin may be required.

diabetes - insulin initiation - insulin initiation ... · pdf filethese guidelines are...

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