Working in partnership with PCTs across Leicestershire and Rutland Date of preparation: May 2008. For review: May 2010. THESE GUIDELINES ARE DESIGNED FOR USE BY THOSE TRAINED AND COMPETENT IN INSULIN INITIATION DIABETES - INSULIN INITIATION - BACKGROUND INFORMATION (1) University Hospitals of Leicester NHS Trust Working in partnership with PCTs across Leicestershire and Rutland INDICATIONS FOR INSULIN: • Newly Diagnosed Type 1 Diabetes • All previous attempts to achieve desired target have failed i.e. lifestyle measures, maximum oral therapy • Persistent failure to achieve desired HbA1c • Patient symptomatic, i.e. weight loss, lethargy • Type 2 Diabetes where early insulin is indicated (see Glycaemic Management Guidelines) • Steroid induced Diabetes • Gestational Diabetes • Post acute myocardial infarction • Intolerance to oral agents • More suitable to patients lifestyle • Acute neuropathies such as proximal amytrophy LOGISTICS FOR INSULIN INITIATION: • Identify dedicated time by competent health care professional for initiation and follow up. • One to one consultations or Group sessions. • Identify and agree the most appropriate insulin regimes (see Insulin Inititiation - Indications for Insulin and Potential Regimens). • Make sure appropriate equipment and educational material is available. • Identify appropriate environment. • Provide ongoing support and contact details. PRINCIPLES OF GOOD PRACTICE: • In Type 2 Diabetes the issue of insulin should be discussed early on in the diagnosis. • In Type 2 Diabetes think about insulin early, i.e. when HbA1c is progressively rising and is consistently above >7.4% and maximum tolerated oral therapy and lifestyle changes are in place. • In Type 1 Diabetes start insulin within 24 hours. • The way in which the subject is approached should be sensitive to the persons needs. • The decision to start insulin should be done in agreement and partnership and the choice of regime tailored to the individual’s needs. • Insulin initiation should be part of a structured care plan and educational programme. • The person should agree to and understand the benefits of insulin; in addition they should also understand the implication of insulin (see Supporting Information (1) and (2)). • The person initiating insulin should be trained and competent. • In Gestational Diabetes insulin should be managed by the secondary care team. (See Referral Criteria to Specialist Services.) Tel: LRI - 0116 258 6403: LGH - 0116 258 4855. • There should be provision for adequate structured follow up. • Access to appropriate dietary advice is essential. • Animal insulins are not recommended for new insulin starts. KEY PRINCIPLES • Many patients with Type 2 diabetes will require insulin therapy. In the UKPDS over 50% of patients by 6 years required additional insulin therapy. • Initiation of insulin therapy in Type 2 diabetes still remains more of an art than a science at the present time, and this area creates much confusion. • It is impossible to produce simple guidelines applicable for every patient with Type 2 diabetes for insulin initiation. There is no clear evidence to suggest that any particular approach has significant advantages over and above an alternative approach. • In normal and overweight patients with Type 2 diabetes, Metformin therapy should be continued at the maximum tolerated dose, as long as there is no contra-indication, e.g. eGFR <30 ml/min (do not initiate if eGFR <45 ml/min), unstable heart failure. (It is important to check that the person has no symptoms of intolerance of Metformin therapy.) POTENTIAL BARRIERS TO STARTING INSULIN: • Occupational issues (See Insulin Initiation - Supporting Information 1). • Fear of injections • Fear of hypoglycaemia • Fear of weight gain Support from DSNs in the community and UHL is available on request (see Diabetes Guidelines). Accredited insulin management training is available locally. Visit www.leicestershirediabetes.org.uk for more information
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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.
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation - background information (1) University Hospitals of LeicesterNHS Trust
Working in partnership with PCTs across Leicestershire and Rutland
indications for insulin:•NewlyDiagnosedType1Diabetes
• ItisimpossibletoproducesimpleguidelinesapplicableforeverypatientwithType2diabetesforinsulininitiation.Thereis no clear evidence to suggest that any particular approach hassignificantadvantagesoverandaboveanalternativeapproach.
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
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - insulin initiation - supporting information (1)
help and supportSupporting literature available from:LeicestershireDiabetesWebsite-forhealthcareprofessionalsandpeoplewithdiabetes. www.leicestershirediabetes.org.uk
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
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
points to rememberInsulinisaffectedbyextremesoftemperaturei.e.veryhotorfreezing.Avoidkeepingincontactwithdirectheatorsunlightor risk of freezing e.g. in the hold of an aircraft.
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.
• 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).
SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYBefore breakfast and before evening meal: Use10unitsb.d.Consideralowerstartingdoseinsomecircumstances,eg.frail,elderlyor‘slim’patients. Remembertheywillneedregularreviewfortitrationofdoses.
• Reducethedoseiffastingglucosefallsbelow4oranunexplainedhypoglycaemicepisodewasexperienced.Theamountofdecreaseneedstobeatleast2-4unitsor10%,whichever is greater.
Keypoint: With the advent of the basal insulin analogues and the advantagesintermsofweightgain,predictabilityandreducednocturnalhypoglycaemia.Itisnotlikelythatthisregimewillremainapopularchoice.SeePotentialRegimens-basalInsulinwithOralHypoglycaemicAgentsorTwiceDailyPre-mixedInsulin.
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
University Hospitals of LeicesterNHS Trust
Date of preparation: May 2008. For review: May 2010.
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
Blood Test Out of Target
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
Blood Test Out of Target
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
Blood Test Out of Target
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
Date of preparation: May 2008. For review: May 2010.
Oral HypOglycaemic agenTs are
lOng acTing insulin is
Blood Test Out of Target
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
Blood Test Out of Target
High = review oral medication
low = review insulin and oral medication
evening meal
Blood Test Out of Target
High = review oral medication
low = review insulin and oral medication
BedTime
Blood Test Out of Target
High = review oral medication
low = review insulin and oral medication
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
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
Intheabsenceof nocturnalhypoglycaemia
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.
Date of preparation: May 2008. For review: May 2010.
meal relaTed insulin is
BackgrOund insulin is
Blood Test Out of Target
High = increase bedtime background insulin (unless hypo overnight)
low = decrease bedtime background insulin
BreakfasT
Blood Test Out of Target
High = increase lunch related insulin
low = decrease lunch related insulin
evening meal
Blood Test Out of Target
High = increase evening meal related insulin
low = decrease evening meal related insulin
BedTime
Blood Test Out of Target
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.
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