The Tayside Diabetes Handbook
Treatment With Insulin

Aim of Insulin Treatment

• To replace endogenous insulin in patients with absolute or relative deficiencies in insulin secretion

 

Optimum Outcome of Insulin Treatment

• Abolish hyperglycaemia and the osmotic symptoms of diabetes
• Optimise blood glucose control and maintain as near normal a blood glucose as is practical and safe for the individual.  Link toknow your numbers
• Maintain an ideal body weight
• Avoid hypoglycaemia
• Provide appropriate self management and tailored education to meet an individual’s need
• Provide appropriate education of carer if self management is not appropriate

 

Principles of Insulin Treatment

• Self glucose monitoring and HbA1c measurements are advised to ensure treatment is effective and targets are met
• Education by the specialist team: DSNs & dietitians, and structured education
• A balance must be maintained between the amount of carbohydrate consumed, insulin administered and exercise taken – all of which can effect the blood glucose
• Education about the management of sick days is essential for people prescribed insulin.  

Starting insulin is best managed as an outpatient, with input from a Diabetes Specialist Nurse and Dietitian.

Insulin therapy in newly diagnosed type 1 Diabetes / suspected type 1 diabetes

 

Patients can be seen urgently (Monday - Friday 9-5 pm) preferably as an out-patient.

Initial review should be with a Diabetes Physician with education and follow up from the Diabetes Specialist Nurses and Dietitians. Type 1 pathway guides follow up with the multidisciplinary diabetes team.

 

Insulin Therapy and Pancreatic Pathology

 

Treatment with insulin may be required in the following:

• Cystic Fibrosis
• Pancreatitis during acute stage and / or long term thereafter.  Individual assessment and monitoring is required
• Carcinoma of the pancreas - individual assessment and monitoring is required
• Insulin therapy will be required following total pancreatectomy
• Insulin treatment may be required for those people who have had surgery to pancreas

 

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Insulin Therapy in Type 2 Diabetes

 

The most common indication for insulin in these patients is worsening glycaemic control on oral agents. The decision to switch treatment to insulin should take account and consideration of the following factors:

• Age
• Other health problems, e.g. complications such as visual loss
• Social circumstances, e.g. patients holding HGV license
• Patient's view
• Patient's weight
• Compliance with healthy eating

 

In general, obese patients who are not losing weight despite hyperglycaemia should have dietary factors addressed as they do not fare better on insulin. However a trial of insulin is justified in any patient with Type 2 diabetes with suboptimal glycaemic control and/or osmotic symptoms 

Frequently, those with Type 2 diabetes gain in weight after starting insulin and in some this can be around 4 kg after 6 months. Patients should be informed that this might occur particularly if they fail to reduce their energy intake and dietetic advice and education is essential.  Patients should continue on metformin, where possible in an to attempt to reduce weight gain with starting insulin (see below)

Education and initial follow up can be provided by the diabetes specialist nurses and dietitians

 

Insulin as Combination Therapy  

 

Insulin & OHA's

• Often patients are advised to continue with their daytime oral agents and are started on a single pre-bedtime insulin injection (usually an Isophane preparation) – known as “Basal Insulin”. The aim is to improve fasting glucose to 5-8 mmol/L (or individual assessment) with insulin and allow oral medication to balance blood glucose during the day.
• If this is insufficient for control, prandial insulin can then be introduced and a decision is taken about rationalizing the oral agents
• This strategy is most often used for obese Type 2 patients.
• Ideally metformin is retained as an insulin-sparing agent.
• The combination of pioglitazone and insulin is occasionally used in insulin resistant individuals, but only under specialist supervision.

The decision to use combined insulin and oral therapy is usually taken after consultation with the specialist diabetes team.  Once daily liraglutide, usually at a dose of up to 1.2mg/day, is the agent of choice in NHS Tayside. For patients who would prefer a once weekly injection, Semaglutide (Ozempic) can be considered.

Liraglutide is available as a combination product with insulin degludec (Xultophy^®) for use where the combination of basal insulin and GLP-1 receptor agonist is appropriate as directed by the specialist Diabetic Team / Diabetes Clinic.

   

Insulin Therapy in the Older Person

 

Chronological age is not a contraindication to insulin therapy. However "biological age" should be a factor in setting appropriate glycaemic targets and in choosing a suitable insulin regimen.

• Targets for glycaemic control in older people need not be as stringent as in the younger patient
• The aim of treatment is to minimise the risk of osmotic symptoms of hyperglycaemia and avoidance of hypoglycaemia.
• It may be best to avoid rapid acting insulin in the very elderly because of the risk of hypoglycaemia
• Regimens using either once or twice daily isophane are often best in this age group
• Consider the need for supervision by community nurses if the HbA1c, blood glucose monitoring results, suggests safety and/or compliance issues.

 

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Starting Insulin

 

All patients starting insulin should have the following:

• Review of dietary intake, with emphasis on regular and consistent carbohydrate intake.
• An individualised regime, which must take account of lifestyle factors such as shift work, holidays, exercise etc.
• Appropriate education on self-management of insulin administration
• Education on avoidance of hypoglycaemia
• Education on "sick day rules", including avoidance of diabetic ketoacidosis for people with Type 1 diabetes.
• See Education Checklist for more information

 

 Principles of Injection

Insulin administration is best taught by a nurse with specialist skills in diabetes.

 

Mixing

• It is important to mix ‘cloudy’ isophane and ‘mixed’ insulin preparations before injection
• Gently tip the pen/vial 10 times and roll between the palms of the hands 10 times to mix it

 

Needles and Technique

• A new insulin pen needle (or syringe) should be used for each injection
• The subcutaneous fat layer varies from person to person and from site to site.
• Needles are available in different lengths, 4mm are sutable for all
• There is no need to swab the skin before or after injection
• Avoid any "lumpy" or atrophic areas
• Inject subcutaneously and maintain the needle in place for 10 seconds
• Do not advise patients to inject through clothes
• Remember that needles should be removed and disposed of carefully after each injection - see Disposal of Sharps.

 

Sites

• The three main areas to inject are the abdomen, upper outer thighs and upper buttocks
• The upper outer arms can be used but care must be taken to reduce the risk of an intramuscular injection
• Rotate sites at each injection
• Using a consistent site for each time of day can help to reliably predict the effect of a dose of insulin
• It is important however to rotate injections within the same site each day.
• Do not mix site and time, as each site has a different absorption pattern

 

Lipohypertrophy.  Repeated injection of insulin into the same area can predispose to the development of an accumulation of subcutaneous fat, which is a local trophic effect of insulin. Insulin will not be absorbed reliably if it is injected into an area of lipohypertrophy and this may result in poor or erratic blood glucose control.

 

Lipoatrophy is another local reaction to insulin, which is due to hollowing of subcutaneous fat. This may be seen in patients with longstanding diabetes who have used animal insulin in the past. However it is rarely seen nowadays as most insulin preparations are highly purified. 

Resource

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Insulin Preparations

 

	Type 1	Type 2	Time of subcutaneous injection (individual assessment recommended)
Isophane Insulin (intermediate acting)
Humulin I  (vial, cartridge, KwikPen)		1st line basal insulin	15 - 20 minutes before breakfast and 15 - 20 minutes before evening meal
Insulatard (vial, Innolet, Penfill)		1st line basal insulin	15 - 20 minutes before breakfast and 15 - 20 minutes before evening meal
Soluble Insulin (short acting)
Humulin S (vial, cartridge)		1st line bolus insulin	15 - 20 minutes before carbohydrate meal
Actrapid (vial,)		1st line bolus insulin	15 - 20 minutes before carbohydrate meal
Mixed Insulin (short/ intermediate acting)
Humulin M3 (vial, cartridge, KwikPen)		1st line mixed insulin	15 - 20 minutes before breakfast and 15 - 20 minutes before evening meal
Mixed Insulin (rapid/ intermediate acting)
Novomix 30 (Penfill, FlexPen)			Approx.15 minutes before breakfast and 15 minutes before evening meal
Humalog Mix 25 (vial, cartridge, KwikPen) Humalog Mix 50 (cartridge, KwikPen)			Approx. 15 minutes before breakfast and 15 minutes before evening meal *
Basal Analogue Insulin (long acting)
Abasaglar (glargine 100u/ml) (cartridge, KwikPen)	1st line basal insulin	2nd line basal insulin if nocturnal hypoglycaemia with isophane	Once or twice daily (Note only licensed for once daily use)
Lantus (glargine 100u/ml) (vial, cartridge, SoloStar)	Lantus replaced by Abasaglar. However, many patients still remain on Lantus. New patients should be commenced on Abasaglar.		Once or twice daily (Note only licensed for once daily use)
Levemir (detemir 100u/ml) (Innolet, FlexPen)			Once or twice daily
Toujeo (glargine 300u/ml) (SoloStar)		2nd line basal insulin if requiring high doses of isophane insulin/nocturnal hypoglyacemia 3rd line basal insulin if ongoing nocturnal hypoglycaemia with   Glargine 100u/ml	Once daily
Tresiba (degludec ) (cartridge, FlexTouch 100u/ml and 200u/ml )	2nd line basal insulin if hypoglycaemia with glargine		Once daily
Xultophy (Liraglutide with insulin degludec) Flextouch		As directed by the specialist diabetes team/diabetes clinic.	Once daily
Prandial Analogue insulin (rapid acting)
Novorapid (vial, Penfill, FlexPen, Flextouch)	1st line bolus insulin		Approx. 15 minutes before carbohydrate intake
Humalog (vial, cartridge, KwikPen)			Approx. 15 minutes before carbohydrate intake
Apidra (vial, cartridge, SoloStar)			Approx. 15 minutes before carbohydrate intake
Fiasp (vial, cartridge, FlexTouch)	2nd line bolus insulin for those who require a faster onset of action		Immediately before or immediately after carbohydrate intakel
Highly concentrated Insulin (short acting)
Humulin R U 500 (500u/ml) (KwikPen)	To be considered in those who require >200units of u100 insulin per day (Link to Humulin R U-500 in handbook)

 

High strength insulin preparations/biosimilar preparation safety information

 

ONSET AND DURATION OF INSULIN

   

 

 

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Insulin Administration Devices

• Insulin pen devices and cartridges of insulin are designed for ‘self use’ only
• Nursing staff should use an insulin syringe to administer insulin to reduce the risk of needle stick injury
• If a patient is unable to administer their own insulin and the preparation does not come in a vial, a suitable alternative insulin preparation should be prescribed
• Cartridges are not interchangeable with different pen devices

 

Insulin Syringes

• 1ml, 0.5ml and 0.3ml syringes with 8mm needles are available on prescription
• Insulin syringes can be used by patients who still wish to mix soluble and isophane insulin
• Insulin syringes can be used to administer large volumes of insulin which cannot be accommodated in a pen device
• Insulin syringes must not be used to extract insulin from a prefilled insulin device or cartridge. The plunger mechanism of the device will be adversely affected if insulin is extracted using a syringe and will not deliver insulin accurately thereafter.

 

Storage of Insulin and Pen Devices

 

Guidelines for the storage of insulin. Specific storage guidelines for each insulin preparation are available in the product package insert.
Unopened vials, pen devices and cartridges	Store in a medicine fridge (2 - 6 degrees C)
Vials (in use)	Document ‘date of first use’ on vial Store in a fridge (2 - 6 degrees C) Discard after  28 days in use Do not use after expiry date Use insulin syringes with 8mm needles
Prefilled insulin pen devices (in use)	‘In-use’ devices can be stored at room temperature (for a maximum of 28 days) appropriately labelled with patient identification. These should be stored in the POD locker, not the ward fridge.
Insulin 3mLCartridges (in use)	‘In use’ cartridges are kept in the pen device appropriately labelled and stored at room temperature for 28 days. In hospital these should be stored in the POD locker, not the ward fridge Do not store cartridge pens in the fridge a the cold can adversely affect the pen mechanism

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disposal of Sharps

• Safe disposal of sharps is essential
• It is the patient’s responsibility to dispose of sharps safely.
• Sharps bins can be provided by community pharmacies, participating GP practices, diabetes clinics and minor injury units.
• The remaining part of the insulin pen device or insulin cartridge can be disposed of in household refuse.
• Used finger pricking lancets and insulin pump sharps should also be disposed of in sharps bins.
• A leaflet is issued with the sharps bin on how to use the sharps bin and where to return it.
• Full sharps bin can returned to community pharmacies, participating GP practices, diabetes clinics and minor injury units.
• Care must be taken at all times to prevent needle stick injury.

Safe disposal of sharps

 

Insulin Regimens and Dose Adjustment

 

See insulin adjustment guidelines in hand book and patient leaflet

 

PRINCIPLES OF DOSAGE ADJUSTMENT

Here are some general guidelines that should be borne in mind when advising on a change in insulin dose

• Many people with diabetes have good insight in to insulin adjustment
• Review trends of glucose rather than changing the insulin dose on the basis of a one off reading
• Identify the periods of day when problems occur and look for a pattern in glucose readings
• Check timing of insulin administration in relation to meals
• Always check monitoring technique/patterns
• Enquire about diet and general health which may affect glucose levels
• Ask about hypoglycaemia
• Check re ability to self manage injections and monitoring
• Check for dexterity/vision issues which may affect self management
• Ask and check about injection technique/lipohypertrophy

 

Signs of over insulinisation

The following symptoms are suggestive of over insulinisation:

• Recurrent hypoglycaemia
• Wildly swinging glucose values
• Weight gain
• Subtle features of chronic hypoglycaemia e.g. headache, hunger, personality change in the older person

 

Continuous Insulin Pump Therapy (CSII)

 

A dedicated multidisciplinary pump service is available in NHS Tayside,see insulin pump protocol in handbook

During weekday working hours the Diabetes team is available for consultation and advice.

Dundee - 01382 633909
Angus - 01241 447811
Perth - 01738 793476