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Treatment with Insulin

Diabetes - Treatment with Insulin

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Insulin Therapy

Insulin therapy is essential for patients with Type 1 diabetes and may be used as a therapeutic option in Type 2 diabetes.

Type 2 diabetes treated with insulin is not Type 1.

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General Principles for Type 1:

Prescribe the types of insulin that allow people optimal well-being.

Try and mimic as closely as possible physiological patterns of insulin secretion.

Attempts to obtain normoglycaemia need to be balanced with risks of hypoglycaemia.

Where possible insulin regimens should be tailored to lifestyle, motivation and capabilities

If an insulin regimen (however unconventional) is effective for an individual then changes should only be advised if this is felt to be unsafe.

Choice of Insulin and Insulin Regimen

Various different insulin regimens are in use.

For any patient the exact dosage and combination of insulins will need to be individually tailored to the patients needs and lifestyle by adjusting doses and type of insulin over time; there are no 'off the peg' insulin dosage regimens.

Commonly used insulin regimens in Type 1 diabetes include:

Basal / bolus: short acting insulin pre-meal with once or twice daily basal insulin.

Twice or three times daily premixed insulins taken premeal. Mixes include variable proportions of rapid and longer acting insulins.

Insulin may also be delivered by continuous subcutaneous insulin infusion (CSII) by pump. The indications for this are covered by NICE guidance.

Inhaled insulin is no longer available.

Use multiple insulin injection regimens in adults who prefer them as part of an integrated package with education, food, skills training and appropriate self-monitoring.

In Type 1 diabetes a single dose insulin regimen may be appropriate in cases where glycaemic control is not a prime consideration such as the very elderly or the terminally ill. A single dose may be used in Type 2 Diabetes as an adjunct to tablet treatment.

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Choice of Insulin Type

 See  - Insulin Wall Chart in Useful Resources and Links section.

The person advising on the insulin dose and regimen should have wide experience of the available choices. Both clinical and lifestyle factors should be taken into account when choosing an insulin regimen.

Meal-Time Insulin

Use unmodified (‘soluble’) insulin or rapid-acting insulin analogues

Rapid-acting analogues:

 

Generally used as first choice

 

Use where nocturnal or late inter-prandial hypoglycaemia is a problem

 

Use to avoid need for snacks, while maintaining equivalent blood glucose control.

 

inject immediately before food;

Soluble insulin:

 

Use if patient eating pattern includes snacking between meals

 

Use if analogues result in hypoglycaemia despite dose adjustment.

 

Inject 20-30 minutes before food.

Basal / Nocturnal Insulin Supply:

Isophane (NPH) insulin
First choice in Type 2 diabetes
Usually need to be injected twice daily.
Less predictable absorption profile.

Use long-acting insulin analogues or isophane (NPH) insulin

Long-acting insulin analogues:
 

Less risk of nocturnal hypoglycaemia than isophane
  Usually once daily injection (may require BD).
  More predictable absorption profile

Mixed Insulins:

Insulin mixtures are usually given twice daily before breakfast and the evening meal. Sometimes 3 or even 4 four injections a day are used if adequate control is not achieved with twice daily injections.

Ready mixed insulin preparations:

 

Available containing a rapid acting analogue or soluble insulin and an longer acting insulin in a fixed proportion eg 30/70 or 50/50

Free mixing:

 

Some patients, usually with long duration diabetes will be ‘free mixing’ using a syringe and two insulin vials.

 

Technically more demanding but allows variation of the rapid: isophane proportion.

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Other Considerations

Erratic and unpredictable blood glucose control: consider:

injection technique

injection sites

resuspension of insulin

self-monitoring skills

knowledge and self-management skills

mismatch between insulin and diet / exercise / lifestyle

psychological and psychosocial difficulties

possible organic causes such as gastroparesis

Injection sites:

Suggested sides are abdomen, thighs and buttocks and arms as long as there is sufficient subcutaneous fat layer.

It is recommended that shorter needles (4-6mm) are used where possible.  See - Forum for Injection Technique (FIT) Guidelines

Differing rates of absorption for human insulins may need to be taken into account (Abdomen > Arm > Thigh > Buttock)

Rotation of sites is recommended to avoid development of lipohypertrophy.

Basal insulins are best injected into a ‘slow’ site.

Monitor injection sites annually or more often if glucose control problem. If patient changes from an area of lipohypertrophy to normal tissue an insulin dose reduction is usually necessary to avoid hypos due to improved absorption.

Concurrent illness: provide guidelines and protocols (‘Sick Day Rules’) prospectively as part of the education programme.

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Insulin Delivery

Provide the device (usually injection pen[s]) that is most suitable for the individual– special devices are useful in some people with special needs (eg visual impairment / needle phobia)

Injection: into subcutaneous fat, It is recommended that shorter needles (4-6mm) are used where possible. See - Forum for Injection Technique (FIT) Guidelines

Disposal of needles: patients on insulin should be provided with information on how to obtain on sharps containers and arrangements for their disposal.

Continuous Subcutaneous Insulin Infusion (CSII / Insulin pumps)

Some patients with Type 1 diabetes may be treated using insulin pumps: all patients should have been given advice about how to manage pump or glycaemic emergencies. They should be directed to the diabetes specialist teams for any problems. If the pump is disconnected or discontinued for any reason at all subcutaneous insulin via injection should be restarted immediately to avoid the rapid development of diabetic ketoacidosis.

 

Those on CSII will need prescriptions for conventional insulin pens (rapid and basal) for use in emergencies as well as the insulin for their pumps.

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Insulin Therapy in Type 2 Diabetes

A significant proportion of patients with Type 2 Diabetes are treated with insulin; such patients are not insulin dependant and insulin is often used as well as tablets in this situation.

Insulin therapy should be offered to people with Type 2 Diabetes with inadequate blood glucose control on optimised oral glucose-lowering drugs and lifestyle modification.

There is little research evidence to inform the choice of insulin type and regimen in Type 2 Diabetes: Local experience, patient preference and relative costs need to be considered as well as the pattern of hyperglycemia in an individual patient.

Clinicians and people using insulin should be aware of the risk of hypoglycaemia and be alert to it.

Oral hypoglycaemic agents may be continued alongside insulin treatment.

Insulin Passport

All those treated with insulin should be issued with the appropriate insulin cards and passport leaflet  - see below.

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Useful External Links & Resources

PDF File

Diabetes UK | Insulin Wallchart

PDF File

Diabetes UK Pen Wallchart

PDF File

FIT Injection Guidelines

PDF File

Insulin Passport - Safe Use of Insulin Leaflet

‘NICE | TA151 Technology Appraisal on Continuous Subcutaneous Insulin Pump’

‘National Patient Safety Suite – Safe use of insulin therapies, Safe use of insulin syringes, pens, pumps and sharps – e-learning modules’

'Diabetes on the net - Six step to insulin safety - e-learning'
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