Insulin Guidelines 080114

Endorsed by Leicestershire Medicines Strategy Group
Leicestershire Diabetes
Guidelines: Insulin Therapy
These guidelines are designed for use by those trained

and competent in insulin initiation and management
in patients with Type 1 and Type 2 diabetes
2013
Leicestershire Diabetes Guidelines: Insulin Initiation and Management
Acknowledgements
This guidance has been developed in line with the National Institute for Health and Care Excellence (NICE) recommendations that:
Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose
titration by the person with diabetes
(Quality Standards in Diabetes 2011). The clinical guidance given is based on NICE Guidance (CG 66)
Specific therapies not as yet formally approved by NICE or not on the Leicestershire Medicines Formulary are included in the guidance
for information only and this is indicated in the text.
The guidance is designed to enable HCPs to gain information on elements of insulin initiation and management on a single page to facilitate
ease of access.
This work is based on the previous excellent guidelines developed by Heather Daly, Nurse Consultant and Professor Melanie Davies.
Many thanks to Shehnaz Jamal for developing the new format of the guidance and also to Professor Melanie Davies, Dr Rob
Gregory, Dr Ian Lawrence, Helen Atkins, Judith Leonard, and the Senior Diabetes Specialist Dietitians for their expert clinical and
practical advice.
June James - Nurse Consultant in Diabetes
Date of Preparation: 25th November 2013

Date of Approval: 5th December 2013
Amended: 8th January 2014
Review Date: 2015
www.leicestershirediabetes.org.uk 2013 Page 2

Contents
Page
Background 4
Indications for Insulin Initiation and Management in Adults 5
Overcoming Barriers 5
Use of Oral and Non - Insulin Therapies in Combination with Insulin 7
Section 1: Introduction to Insulin 9
Actions of Insulin 10
Insulin Strengths 12
Section 2: Potential Insulin Regimens for Type 2 diabetes
1. Basal Insulin with Oral Hypoglycaemic Agents: Once Daily Basal Insulin 13
2. Twice Daily Pre - Mixed Insulin 15
3. Basal Bolus Regimen 17
Section 3: Lifestyle Factors 19
Hypoglycaemia 21
Treating Hypos 23
Section 4: Managing Insulin During Illness in Type 1 and Type 2 24
General Principles of Managing Sick days 26
Sick Day Management 27
Section 5: Insulin Administration and Devices 28
Types of Insulin Delivery Devices 30
Injecting Insulin 32
Section 6: Insulin Safety - Safe Use of Insulin 34
Insulin Safety: Sharps 35
Help and Support 36
Appendices
Appendix 1: TREND-UK competency document 37

Appendix 2: End of Life Diabetes Management - Algorithm for Glycaemic Control 38
Appendix 3: End of Life Diabetes Management - Managing Glucose Control on Once Daily Steroids 39
Page 3
Background
There are 3 million people with diabetes in the United Kingdom

8% of these people will have Type 1 diabetes and these people will require insulin within 24 hours after diagnosis
and continue it life long
50% of the remaining 92% with Type 2 diabetes will require additional insulin therapy within 6 years of diagnosis

Indications for Insulin Initiation and Management in Adults
Consider starting insulin in
People with Type 2 diabetes (T2DM) People with Type 1 diabetes (T1DM)
If there is failure to reach glycaemic targets using diet and non In Type 1 diabetes Insulin needs to be started within
insulin therapies (NICE CG 66, 87) 24 hours of diagnosis
If the individual is symptomatic If the patient is severely ketotic and or vomiting, pregnant, or
e.g. rapid weight loss, polyuria, nocturia a child urgent referral / telephone contact to the specialist
If the individual has Gestational Diabetes (these women need team or acute on call medical team is required
to be managed in specialist care) T: LRI 0116 258 5545 or hospital switchboard (0300
T: LRI 0116 258 6403 LGH 0116 258 4855 3031573) and ask to speak to a diabetologist or paediatrician
In steroid induced diabetes (see Insulin and steroid section or acute on call medical team
(page 20) Out of hours may well be the on call medical team who deal
If the patient is post myocardial infarction with this
If the individual is intolerant to non- insulin therapies
If the individual has acute neuropathies such as femoral amytrophy
Where and when to initiate insulin Allaying fears of starting insulin
Insulin therapy can be initiated in the community or hospital To allay some of these fears in T2DM it is important to introduce
setting but it needs to be initiated by an appropriately trained the possible progression to insulin soon after diagnosis
and competent health care professional (See appendix 1 for
TREND-UK competency document) Healthcare professionals initiating insulin should be trained
Insulin can be initiated in a group session or and competent (An integrated Career and Competency
in a one to one consultation Framework and www.trend-uk.org TREND-UK)
There should be protected time for initiation and follow up Discussion on the need to start insulin should be approached
sensitively and should be tailored to an individuals level of
Appropriate equipment and educational material including understanding and language
information on where to seek advice and on going support
should be available The benefits and challenges of using insulin must be discussed
with the individual
Different insulin regimens and delivery devices should be
tailored to the individuals clinical need and preferences The decision to start insulin must be done in agreement with
the individual and / or their family or carer
The choice of regimens should be made in accordance with
the patients clinical needs and preferences
Barriers to starting insulin
Insulin initiation should be part of a structured care and
education plan including appropriate follow up
These often centre on an individuals prior understanding of the use Individuals commencing insulin should have a dietary review
of insulin and can include:
Fear of injections
Fear of hypoglycaemia
Concerns about potential weight gain
Concerns about the individuals job (e.g. those who drive
for a living, taxis, lorries or if the patient is a member of the
armed forces)
Cultural issues
Page 5
Glucose Lowering Therapies Algorithm
Figure1 Ref: Leicestershirediabetes Guidelines 2012
Glucose Lowering Therapies - Algorithm for T2DM
HbA1c > 48mmol/mol (6.5%) Consider Sulphonylurea here if:

after trial of lifestyle interventions Not overweight (tailor the assessment of
body weight associated risk according to Sulphonylurea
ethnic group)
If Metformin is not tolerated or
Metformin (with dose titration) is contraindicated HbA1c <
A rapid therapeutic response is HbA1c >
48mmol/mol
required because of hyperglycaemic 48mmol/mol
(6.5%) monitor
symptoms (excess thirst/ frequent (6.5%)
HbA1c < for deterioration
HbA1c > urination/ modest weight loss)
48mmol/mol 48mmol/mol
(6.5%) (6.5%) monitor
Consider adding a DPP-4 inhibitor or
for deterioration
SGLT-2 or pioglitazone or if the patient
Consider substituting a DPP-4 is obese (BMI > 30 ) consider early use of
Metformin + Sulphonylurea inhibitor or SGLT-2 inhibitor* or a GLP-1 agonist
Thiazolidinedione (Pioglitazone) for
the Sulphonylurea if there is a
significant risk of hypoglycaemia (or Sulphonylurea +
HbA1c < its consequences) or a Sulphonylurea DPP-4 inhibitor or SGLT-2 or Pioglitazone
HbA1c >
58mmol/mol is contraindicated or not tolerated in obese subjects consider GLP-1 agonists
58mmol/mol
(7.5%) monitor
(7.5%)
for deterioration
Metformin +
DPP-4 inhibitor or SGLT-2 or Pioglitazone HbA1c <
HbA1c >
58mmol/mol
58mmol/mol
(7.5%) monitor
(7.5%)
Consider adding a DPP-4 inhibitor or SGLT-2 for deterioration
inhibitor or Pioglitazone instead of insulin if
insulin is unacceptable (because of Metformin + Sulphonylurea + DPP-4 inhibitor
employment, social, recreational or other or Metformin + Sulphonlyurea or SGLT-2 or
personal issues, or obesity). Consider Pioglitazone
adding a GLP-1 agonist to Metformin and a or Metformin + Sulphonylurea or GLP-1 agonist
Add insulin particularly if the person is
Sulphonylurea if:
markedly hyperglycaemic
BMI 35kg/m2 in people of European
Insulin + Metformin + Sulphonylurea descent and there are problems
associated with weight, or
HbA1c <
BMI - 30 - 35kg/m2 and insulin is HbA1c >
58mmol/mol
HbA1c < unacceptable because of occupational 58mmol/mol
(7.5%) monitor
HbA1c > implications, sleep apnoea or (7.5%)
58mmol/mol for deterioration
58mmol/mol
(7.5%) Monitor Weight loss would benefit other co-
(7.5%)
for deterioration morbidities
Start insulin
Increase insulin dose and intensify regimen

over time. Consider DPP-4 or SGLT-2 or HbA1c <
HbA1c >
Pioglitazone with insulin if blood glucose 58mmol/mol
58mmol/mol
control is inadequate with high dose insulin (7.5%) monitor
(7.5%)
(be aware of risk of bladder cancer and heart for deterioration
failure in patients on Pioglitazone).
Glucagon-Like Peptide-1 receptor agonists (GLP-1 agonists)

Can be used in very obese patients and those intolerant of Metformin and Sulphonylureas
Can be used in combination with a single oral agent All patients using insulin should be issued
Lixisenatide, Exenatide and Exenatide extended release can be used with basal insulins with a safe use of insulin booklet and
Insulin Levemir can be used in addition to Liraglutide insulin passport / insulin safety card.
www.leicestershirediabetes.org.uk
Sodium Glucose Co-Transporter 2 inhibitors (SGLT-2 inhibitors)
These are a new class of oral drugs for the treatment of Type 2 Diabetes. They inhibit glucose re-absorption in
the proximal renal tubules providing an insulin independent mechanism to lower blood glucose.
5/12/13
Please check http://leicestershire.formulary.co.uk for preferred choices and traffic light status

Introduction to Insulins
Use of Oral and Non - Insulin Therapies in Combination with Insulin
Often the treatment of people with Type 2 diabetes over time will result in individuals requiring a combination of non insulin therapies and insulin.
Lifestyle changes and diet are a key factor in management throughout an individuals treatment plan and individuals are usually commenced on
Metformin as monotherapy from 6 weeks unless there is contraindication or there are other management or clinical issues. If glycaemic control is not
optimised then various options are given for consideration with the introduction of insulin recommended usually as third line treatment unless the
individual has osmotic symptoms. The algorithm shown on page 6 gives examples where combination therapy may be appropriate.
Factors influencing the choice of insulin regimen T2DM Which insulin should be used initially for T2DM
The individuals lifestyle consider: Animal insulin is no longer used for insulin starts
Usual meal times Begin with human NPH insulin injected at bed-time or twice daily
according to need such as Insuman Basal, Humulin I or Insulatard
Does the patient work shifts?
Is travel involved in their daily work?
Consider, as an alternative, using a long-acting insulin analogue such as
Do they drive a taxi or hold an HGV license?
Insulin Detemir, Insulin Glargine if:
(consider driving restrictions)
Is the number of injections per day an issue? The person needs assistance from a carer or healthcare
professional to inject insulin, and use of a long-acting insulin
Are they at risk of hypoglycaemia? analogue (Insulin Detemir, Insulin Glargine) would reduce the
Will dexterity be a problem? frequency of injections from twice to once daily, or
Is weight an issue? The persons lifestyle is restricted by recurrent symptomatic
hypoglycaemic episodes, or
Health beliefs and culture
The person would otherwise need twice-daily NPH insulin
injections in combination with oral glucose-lowering drugs, or
Factors influencing the choice of insulin regimen T1DM The person cannot use the device to inject NPH insulin
The individuals lifestyle consider:

Consider twice daily pre - mixed (biphasic) human insulin
Usual meal times
(particularly if HbA1c 75 mmol/mol or 9%)
Does the patient work shifts?
Is travel involved in their daily work? Consider pre-mixed preparations that include short-acting insulin
analogues, rather than pre-mixed preparations that include short-
Do they drive a taxi or hold an HGV license? acting human insulin preparations, if:
Consider driving restrictions
Is the number of injections per day an issue? A person prefers injecting insulin immediately before a meal, or
Are they at risk of hypoglycaemia? Hypoglycaemia is a problem, or
Will dexterity be a problem? Blood glucose levels rise markedly after meals
Is weight an issue?
Consider initiation of pre - mixed insulin if the A1c is high
Health beliefs and culture particularly above 75 mmol/mol or 9%
In Type 1 patients a basal bolus regimen is usually commenced
in the majority of individuals. This would however depend on the
individual patients preference and convenience This would however depend on the individual patients
preference and convenience.
In the early weeks and months following the diagnosis of T1DM the
amounts of insulin required are often very small (honeymoon phase)
Page 7
Use of Oral and Non - Insulin Therapies in Combination with Insulin
Table 1: Use of oral and Non Insulin therapy in combination with Insulin
Oral and Non - insulin

Use with Insulin Contraindications
therapy
Do not use Metformin if the individual is:
Normal and overweight people with Type 2 diabetes can be
Intolerant of Metformin
continued on Metformin as there is evidence that this combination
Metformin In heart failure
is insulin sparing and has other benefits including weight
Do not start if eGFR is less than 45 mls/min
management glycaemic control and cardiovascular disease (CVD)
Discontinue if eGFR is < 30 mls/ min
Use with caution / do not use in vulnerable
Continue with regular dose reviews if the individual is on a daily
people that are at risk of hypoglycaemia, e.g.
Sulphonylureas (SU) isophane or analogue insulin. Otherwise the dose is usually halved
elderly, dementia, those with deteriorating
or discontinued
renal function and those who live alone.
DPP-4Is licensed for use with Insulin are: Sitagliptin (Januvia),

DPP-4Is are contraindicated in women of
DPP-4 Inhibitors (DPP-4Is) Linagliptin (Trajenta) and Saxagliptin (Onglyza). LMSG recommends
child bearing age considering pregnancy*
Sitagliptin and Linagliptin as preferred choice.
Acarbose Not recommended in combination with Insulin

Do not use if there is a history of heart failure /
Pioglitazone Caution as there is a risk of fluid retention and weight gain bladder cancer / bone fractures or if the patient
has macroscopic haematuria.*
Requires careful monitoring particularly if GLP-1 agonists are Do not use if there is a history of acute
Glucagon-like peptide-1 commenced after insulin initiation, in these cases the insulin pancreatitis
receptor agonists. dosage is normally halved when the GLP-1 is commenced. Use in CKD patients varies according
(GLP-1 Agonists) Lixisenatide and Exenatide are short acting GLP-1s and affect post to specific GLP-1. (e.g. Lixisenatide can
Exenatide extended release prandial blood glucose. Bydureon and Liraglutide are long acting be used in patients whose eGFR > 30
Exenatide twice daily, and predominately affect fasting glucose. mls/min)
Liraglutide once daily Lixisenatide is first line choice on the Leicestershire Medicines Type 1 diabetes
Lixisenatide Formulary leicestershire.formulary.co.uk (Refer to manufacturers Severe gastrointestinal disease
instructions for each individual product for use with insulin) Pregnancy.
Do not use if eGFR is less than 60mls/Min If
used with insulin and an SU the dose of the
NICE has recommended that Dapagliflozin , (Forxiga) can only be
+
Sodium glucose co- SU should be lowered to reduce the risk of
used as mono therapy or as part of combination therapy alongside
transporter 2 hypoglycaemia.* It is not recommended for
Metformin or insulin. (Ref: NICE TA288)
SGLT-2 use in combination with Pioglitazone or
DPP-4s and GLP-1s see formulary: http://
leicestershire.formulary.co.uk
*Please review individual manufacturers guidance on use in pregnancy
Sodium glucose co-transporter 2 inhibitors (SGLT-2 inhibitors)
These are a new class of oral drugs for the treatment of Type 2 diabetes. They inhibit glucose re-absorption in the proximal renal tubules
providing an insulin independent mechanism to lower blood glucose.

Section 1: Introduction to Insulin
Background
There are over 20 different types of insulin; these fall into four main types:
Rapid acting Intermediate acting
Short acting Long acting
The right insulin regimen is required to address both basal, i.e. fasting and pre-prandial glucose levels and post - prandial (post meal) excursions.
Rapid acting insulin analogues:

Such as NovoRapid (Aspart) and Humalog (Lispro) and Apidra (Glulisine) have advantages in terms of convenience can be injected with food ,
or indeed, post prandial. They are better at controlling post prandial glucose with less need for snacks and have a lower risk of hypoglycaemia.
Short acting non- analogue insulins:

Addresses post - prandial glucose excursions, either used alone or in combination as a mixed insulin. The disadvantages are that some have to be
injected 20 - 30 minutes before a meal. Patients may need to snack between meals and there is a risk of hypoglycaemia.
Intermediate acting insulin:

A traditional isophane, given twice daily such as Humulin I, Insuman Basal and Human Insulatard addresses basal hyperglycaemia.
Intermediate- acting insulin has a longer life span than rapid or short- acting insulin but is slower to reach a peak.
Cloudy insulin always contains some intermediate acting insulin.
Long acting insulin analogues:
Insulin Glargine (Lantus), Insulin Detemir (Levemir) and Insulin Degludec (Tresiba) have the advantage of greater predictability, potentially less
weight gain, and lower risk of hypoglycaemia, particularly at night compared to intermediate acting insulin. They can be given as a basal insulin or
in a Basal Bolus regimen.
Mixed insulins:
Such as NovoMix 30, Insuman Comb 15 and Humalog Mix 25 will contain a proportion of rapid or short acting and intermediate acting insulin Mixed
Insulin contain a mixture of isophane which is intermediate acting insulin and short or rapid acting insulin the number given. (e.g. NovoMix 30 indicates
the proportion of short or rapid insulin include in the preparation.)
Targets of therapy T2DM Titrating doses - key principles
Review trends in capillary blood glucose (CBG) readings rather

Agree individual glycaemic targets with the patient and
than individual / random results. Using the monitoring diary
where possible in line with NICE guidance. NICE recommends:
or electronic meter memory to establish if patterns exist at
An HbA1c value of 48 mmol/mol (6.5%) in patients with different times of the day
newly diagnosed and on up to two different classes of glucose
Consider any comments discussed or recorded in the
lowering therapy
monitoring diary. Are they related to the CBG readings (e.g.
In patients on more than two glucose lowering medications eating patterns, changes in activity)
the target HbA1c is 58 mmol/mol (7.5%)
View the blood glucose results in relation to the type of insulin
Aim for a pre-breakfast or fasting glucose level of <5.5mmol/l and timing of injections
and pre-prandial levels at other times of the day at <6mmol/l
Is the problem dose related or does it indicate that the
Aim for post-prandial (i.e. 2 hours after a main meal) regimen is not meeting that persons needs?
<8mmol/l but this will depend on the individual,
Generally, increases are made in 10% increments
(e.g. in the elderly or end of life care these targets may not
be appropriate). Prevention of hypoglycaemia takes precedence and generally
where no other cause can be found a 20% reduction in
insulin dose is required with careful monitoring
Deterioration in renal function may lead to a risk of
hypoglycaemia in insulin users so doses need regular
monitoring and titration
Look for other presenting factors (i.e. renal function, adrenal
function, thyroid or significant change in lifestyle or diet).
Page 9
Actions of Insulin
Metformin can be continued in combination with all insulin regimens, as outlined here, in patients with Type 2 diabetes:
Rapid-acting Insulin Action e.g. NovoRapid , Humalog, Apidra
Rapid-acting insulin begins working very quickly inside the body, usually within
Onset: 5-15 mins 5 - 15 minutes. This type of insulin should be taken just before eating. It peaks
Insulin Activity
Peak: 0.5-1.5 hours

Duration: 3-5 hours
between 30 and 90 minutes and its duration is typically between 3 and 5
hours. As the activity of rapid-acting insulin starts and finishes so quickly, it is
recommended to be taken with food or straight after eating, therefore it is
less likely to lead to hypoglycaemia compared with other insulin preparations.
0 2 4 6 8 10 12 14 16 18 20 22 24
hours
! Be aware doses may need reducing 1 hour before planned
exercise and subsequent doses within a 24hr period.
Short-acting Insulin Action e.g. Soluble Human Insulin: Actrapid, Humulin S, Insuman Rapid
Short-acting insulin begins working in the body between 30 and 60 minutes after
injection. Typically, short-acting insulin peaks between 2 and 4 hours, and its
Onset: 30 mins durations is typically 6 - 8 hours. As a result of its relatively short lifespan, short-
Peak: 2-4 hours acting insulin may need be injected several times during the day.
Insulin Activity
Duration: 6-8 hours
! Can put patients at risk of hypos late in the morning or early hours of the
night (2am) depending on the timing of the dose.
0 2 4 6 8 10 12 14 16 18 20 22 24
Hours
Intermediate-acting insulin Action e.g. Humulin I, Human Insulatard, Insuman Basal
This type of insulin is cloudy and has a longer lifespan than short-acting insulin but it
is slower to start working. Intermediate-acting insulin is usually starts working within
Insulin Activity
Onset: 2-4 hours

2 - 4 hours after injection, peaks somewhere between 4 and 8 hours and remains Peak: 4-8 hours
Duration: 14-16 hours
working for approximately 16 hours. Occasionally this insulin is given twice daily.
! Re-suspension of intermediate acting insulin is critical. If this is not done

glycaemic control can be erratic. 0 2 4 6 8 10 12 14 16 18 20 22 24
hours
Long-acting Insulin Action e.g. Glargine (Lantus), DetemirLong

(Levemir),Insulin
acting basal analogues
Degludec ( Tresiba)
This type of insulin starts working within 2 hours and provides a continuous level Onset: 0-2 hours
Peak: None
of insulin activity for up to 24 - 36 hours depending on the specific preparation
Insulin Activity
Duration: 18-42 hours
- please refer to the manufacturers guidance for individual products. Insulin

Degludec (Tresiba) can last for up to 42 hours.
0 4 8 12 16 20 24 26 30 32 34 36 40
Hours

Example of Insulin Regimens
Insulin Regimen: Basal Bolus e.g. Intermediate and short acting

Once or twice daily basal insulin in combination with OHA or prandial insulin
Basal Twice
Insulin daily basal bolus Basal bolus using B.D.
isophane and prandial Short acting Insulins
Peak: 2-6 hrs
Duration: up to 24hrs
insulin - 4 injections per day
Insulin Activity
Long acting Insulin
3 analogue rapid / short + 1 Long acting Insulin
Insulin Activity
non-analogue intermediate Long acting Insulin
acting insulin
0 2 4 6 8 10 12 14 16 18 20 22 24
8am 12pm 6pm 8pm

Night time
Breakfast Lunch Dinner bedtime
0 2 4 6 8 10 12 14 16 18 20 22 24 Hours of action
Hours
Insulin Regimen: Twice daily pre - mixed insulin
This includes conventional mixtures of short-acting and isophane insulin, e.g. Insuman Comb 15, Comb 25, Comb 50 and Humulin M3. The most
commonly used ratio is 30 / 70. Insulin analogue mixtures are available with a percentage of short-acting insulin of 25%, 30% and 50%. Short-
acting insulin analogue mixtures such as Novomix 30, HumalogMix 25and Humalog Mix 50, are now available.
These analogue preparations may have particular advantages in terms of patient convenience (no need to wait before eating) and control of post-
meal glucose.
If an individual has a higher HbA1c, head to head studies have shown greater efficacy if pre - mixed regimens are used and particularly evident in
those with a less high BMI
Pre-mixed Analogues e.g. NovoMix 30, Humalog Pre-mixed Human insulin e.g.
Mix 25, Humalog Mix 50 Humulin M3, Insuman Comb 15, Comb 25, Comb 50
Pre-mixed human soluble/isophane:

Pre-mixed Analogues/Isophane:
Rapid acting Short acting

Onset: 5-15 Onset: 30 mins
Peak: 1-4 Peak: 2-8 hrs
Duration: 24
Insulin Activity
Insulin Activity
Long acting
Long acting
0 2 4 6 8 10 12 14 16 18 20 22 24 0 2 4 6 8 10 12 14 16 18 20 22 24
Hours of action Hours of action
The peak of action varies with individual products
Page 11
Different Insulin Formulation and Concentration
U100 strength insulin is the preparation most commonly used

in the UK, this delivers 100 units of insulin in 1ml. However a U 500 insulin
low volume concentration is now available. (See Leicestershire
Medicines Formulary http://leicestershire.formulary.co.uk) U500 strength insulin e.g. Humulin R is
sometimes used in people who are insulin
resistant and require the equivalent or more than
Insulin Degludec (Tresiba) 300 units of U100 strength insulin per day.
This product is not licensed in the UK but is still

A U200 strength long acting analogue insulin, sometimes prescribed. It :
Insulin Degludec (Tresiba) is now available this delivers the correct
amount of insulin in units but in half the volume. Is soluble
Is five times (5x) more concentrated than U100 insulin
The U200 insulin preparation is available in an insulin Flex
Touch pen only. This device can be used to dial up to 160 Is normally injected three times a day
units.
Must be prescribed by a Diabetes Specialist on an named patient basis
Insulin Degludec (Tresiba) is also available in the traditional
An independent nurse or pharmacist prescriber or Diabetes
U100 strength insulin for people on smaller doses (up to 80
Specialist Nurse, can adjust the dosage (local guidance only)
units) and is available in a cartridge or a Flex Touch pen device
Be aware the packaging is similar! Can be used in an insulin pump
The National Patient Safety Agency (NPSA) advise to always write
the word strength in when prescribing U200 insulin (e.g. U200
strength Insulin Degludec).
If patients dial up this insulin by counting the clicks they
should be advised that each click accounts for 2 units of insulin
Warning !
* Please note this preparation has been sanctioned by NICE and
can be found on the Leicestershire Medicines Formulary (http:// Insulin should NEVER be drawn up from an insulin
leicestershire.formulary.co.uk ) cartridge or pre-filled pen using a syringe as the
dose given would not be accurate.
Always check that the correct strength of

Degludec (Tresiba) is prescribed

Potential Insulin Regimens for Type 2 Diabetes
Section 2: Potential Insulin Regimens for Type 2 Diabetes:
Basal insulin with Oral Hypoglycaemic agents

1. Insulin regimen: Once-daily basal insulin in combination with oral hypoglycaemic agent
Either long-acting insulin analogue, Insulin Glargine (Lantus), Insulin Detemir (Levemir) or Insulin Degludec (Tresiba) or
isophane insulin (Humulin I, Insulatard, Insuman Basal) with continued oral hypoglycaemic agents.
Once-daily basal insulin in combination with oral hypoglycaemic agent to include either a
Sulphonylurea or a prandial glucose regulator with Metformin if tolerated.
Evidence suggests that conventional isophane insulin when used in this regimen is best administered either in the evening or before bed.
Basal insulin analogues including Insulin Glargine, Insulin Detemir or Degludec have been suggested for use once a
day in combination with oral agents as they have particular advantages in terms of nocturnal hypoglycaemia.
Once a day insulin analogues are designed to work throughout a 24 hour period with a peakless
action. The length of action varies with each of these, refer to manufacturers guidelines.
Pre - breakfast (fasting) blood glucose readings are a good indicator of their effectiveness, but remember that some
individuals may require a BD dose of a long acting analogue, e.g. BD dosing more likely with Detemir. 30% of patients
in the 4T study required a second dose of insulin Detemir. (Ref: Holman R et al 2009, NEJM 361:1736-1747)
The peakless insulins are not effective in lowering meal-time (prandial) rises in blood glucose. If this cannot be adequately
controlled with long-acting insulin and oral hypoglycaemic agents, short acting insulin will need to be added.
Basal insulin analogues should not be mixed in syringes with other insulins.
Should ideally be injected at approximately the same time every day.
Your choice of oral hypoglycaemic agent, particularly the insulin secretagogue (SU), may be important if choosing this regimen.
Always continue Metformin in the normal and overweight patients at the current dose unless contra-indicated or not tolerated.
Always check for symptoms of Metformin intolerance in patients. Pioglitazone can be continued when commencing basal insulin.
Continue previous Sulphonylurea at unchanged dose. For ease of therapy one may wish to consider a change to once-
daily Glimepiride titrated up to a dose of 4 - 6 mg or Gliclazide MR. This is a good choice if ease of administration
is an issue. If weight or hypoglycaemia is an issue consider an SGLT-2 or DPP-4 with basal insulin.
The insulin cannot be drawn up and left for injection later. (RCN)
Advantages Disadvantages
The 4T study indicates that in patients with Type 2 Individuals may not achieve optimal control and may
diabetes and a baseline HbA1c < 8.5% a once daily basal require a BD dose
insulin regimen is effective and safe with a lower risk of
The regimen may not offer optimum control of post-meal
hypoglycaemia and weight gain.
(post-prandial hyperglycaemia)
It is simple and easy for early facilitation to insulin
Some individuals may require a more intensified
Potentially less weight gain insulin regimen
Potential for less risk of hypoglycaemia
Relatively easy regimen for healthcare professionals
to support
Useful for symptom relief if tight control is not a major issue
Page 13
Once-daily basal insulin in combination with oral hypoglycaemic agent
Simple approach to initiation of Insulin therapy
Use 10 units once daily usually given at bedtime (9 - 10pm) or with evening meal for isophane
You may need to consider a higher dose in people with insulin resistant Type 2 diabetes depending on their weight
Most individuals will ultimately require between 0.5 - 0.7 units of insulin per kilogram of weight, so in an individual weighing 100kg a daily
dose of 50 - 70 units may be required
Long-acting analogues may be given morning or evening at a time suitable for the patient, but it ideally should be consistent from day to day
There is some debate regarding the use of analogue versus non analogue insulin. Data suggests that analogues are more effective at
lowering plasma glucose and have a lower rate of nocturnal hypoglycaemia compared with non analogue insulin
Consideration should be given to transfer to an analogue insulin if the individual is experiencing hypoglycaemia
Group starts for introducing insulin therapy are a cost effective way of using resources also individuals may benefit from group interaction
and receive consistent training in dose titration
Titration of doses Indication for change of regimen
Basal Insulin Regimen Fasting glucose levels are at target but if post-prandial
glucose levels remain high despite maximum tolerated oral
Aim for fasting plasma glucose level 5.5mmol/l - 6.0mmol/l, agents, it may be appropriate to stop these and change to a
increase insulin Glargine or Insulin Detemir dose 2 units formal basal bolus regimen. (See relevant guidances)
every 3 days until agreed targets are reached and there is no Control remains suboptimal
nocturnal hypoglycaemia
Recurrent unresolved hypoglycaemia
Although basal analogues are designed to work throughout a
24 hour period, this may vary between 16 - 42 hours Patients preference or need for greater flexibility with regard
to lifestyle (e.g. exercise, employment)
If the insulin is taken in the morning consider that raised
fasting glucose levels may be due to inappropriate diet and or
the insulin running out rather than inadequate dosage
NB raised fasting glucose levels may also be due to nocturnal Choice of oral hypoglycaemic agent
hypoglycaemia!
Remember: Your choice of oral hypoglycaemic agent, particularly the insulin
Use three consecutive self-monitored fasting glucose levels secretagogue (SU), may be important if choosing this regimen.
(before breakfast) to adjust doses
Always continue Metformin in the normal and overweight patients
Wait 3 - 4 days between dose adjustments at the current dose unless contra-indicated or not tolerated
Reduce the dose if fasting glucose falls below 4 or an Always check for symptoms of Metformin intolerance in patients
unexplained hypoglycaemic episode was experienced. The
amount of decrease needs to be at least 2 - 4 units or 20%, Continue previous Sulphonylurea at unchanged dose unless
whichever is greater you are giving a pre-mixed regimen or prandial insulin then
discontinue the Sulphonylurea. Or consider DPP-4 or SGLT-2 in
You may need to advise blood glucose testing during the night combination with insulin if weight or hypo is an issue
if you suspect nocturnal hypoglycaemia (3am)
Basal plus regimens
A basal plus regimen is sometimes required in individuals to

improve glycaemic control this would comprise of a once daily
intermediate/ long acting insulin with a prandial dose of fast acting
insulin given with either the main meal or the meal that produces
the greatest post prandial glucose excursion. The starting dose of
the prandial insulin is usually 10% of the total daily dose of the
basal insulin and is limited to a dose of between 4 and 6 units

Twice daily pre - mixed insulin
2. Twice daily pre - mixed insulin
Either conventional short-acting and isophane insulin (e.g. Insuman Comb 15, Comb 25, Comb 50, Humulin M3) or
analogue mixed insulin, (e.g. NovoMix 30, Humalog Mix 25 or Humalog Mix 50).
The advent of short-acting insulin analogue mixtures means that this regimen is now available as fast acting in the analogue insulins, either as:
NovoMix 30 with 30% short-acting insulin analogue or
Humalog Mix 25 (25% short acting insulin analogue), or Humalog Mix 50 ( 50% short acting insulin analogue)
The particular choice of which pre - mixed insulin is used may be influenced by:
Choice of insulin injection device

Perceived convenience for individuals
Potential for weight gain and risk of hypoglycaemia
This regimen is relatively easy to teach and simple There is less flexibility (i.e. unable to adjust the short or
for the patient to understand basal component of insulin independently)
It has potential for better post-prandial glucose control Patients may not achieve optimal glycaemic control
Is more effective in lowering HbA1c than Time delay of injection with conventional mixture
basal insulin alone (need to inject 20 - 30 minutes before a meal)
Particularly if the patient has a higher HbA1c (>9%), as The need for snacks between meals
most head to head studies have shown greater efficacy if (with the new analogue mixture the delay in injection time
pre - mixed and particularly in those patients with not such is not required and the need for snacks may be reduced)
a high BMI
Titration may get complicated and difficult to teach
Increased risk of hypoglycaemia and weight gain
(Early data from the 4T study - Ref: Holman R et al 2009,
NEJM 361:1736-1747)
Simple approach Initiation of insulin therapy in Type 2 diabetes
Before breakfast and before evening meal:
Use 10 units BD. Consider a lower starting dose in some circumstances, (e.g. frail, elderly or slim patients)
Page 15
Titration of doses Indication for change of Regimen
Morning dose of insulin titrated against pre-lunch and pre- If glycaemic targets are not reached after titration, change may be
evening meal blood glucose tests: suggest 2 unit increments or required. For example:-
10% increase with a target glucose of < 6mmol/l before lunch
and before evening meal. If control remains suboptimal (HbA1c targets or fasting blood
glucose or both)
Evening dose titrated against pre-bed and pre-breakfast test.
Titrate by 2 unit increments or 10% increments to try to achieve Hypoglycaemia (particularly during the night)
a before breakfast blood glucose of 5.5mmol/l - 6mmol/l.
Excessive weight gain despite continued Metformin
Beware of before bed tests of < 6mmol/l : aim for a before bed
test between 6mmol/l and 8mmol/l. Patients preference or lack of flexibility with the regimen for
Watch carefully for the risk of nocturnal hypoglycaemia. patients to undertake lifestyle (e.g. erratic job or exercise)
In patients with Type 2 diabetes and BMI >19, Metformin If before the evening meal dose blood glucose remains high but
therapy should be continued at the maximum tolerated dose, further titration causes mid-morning hypoglycaemia.
as long as there is no contra-indication, (e.g. eGFR <30ml/min, There are several options:
unstable heart failure).
1. Continue premixed insulin and add in rapid / short
(It is important to check that the person has no symptoms of
acting insulin at lunchtime if high blood glucose
intolerance of Metformin therapy).
before evening meal.
2. Stick to pre -mix twice a day but change the
proportions of insulin (e.g. Humalog Mix 50).
3. Offer the patient free mixing of insulin. However, the
disadvantage of this is that it is complicated to explain
and teach to patients, accuracy is an issue, and the
patients would need to move away from a pen device
back to a needle and syringe.
4. Basal Plus
5. Once you add prandial insulin whether in pre-mix or
as once daily prandial, you should discontinue the
Sulphonylurea. You should make sure that the basal
insulin has been adequately titrated.
With the basal plus you tend to add the first injection
of prandial insulin to the largest meal or the meal that
produces the greater post prandial glucose excursion
and the starting dose is 10% of the total daily dose
of basal insulin limited to a minimum of 4 and a
maximum of 6 units.
Alternative approaches to insulin initiation for

advanced practitioners
The approach to insulin therapy is continuously changing.

Recent evidence suggesting a more proactive and calculated dose
and titration may be appropriate for those experienced in insulin
management. To adopt this approach see the Leicestershire
Diabetes website for education / training details e.g. the EDEN
project. www.leicestershirediabetes.org.uk
An accredited Masters level training module on insulin initiation

and management is available.
See www.leicestershirediabetes.org.uk for details

Basal Bolus Regimen
3. Basal Bolus Regimen
At least four injections of insulin per day An example of someone in whom this may be useful is an
active, motivated person with an erratic lifestyle to improve
Short - acting non analogue or a rapid-acting analogue before
each meal (either once or twice daily isophane or long acting glycaemic control.
insulin analogues, (e.g. Glargine, Detemir or Tresiba)
Often used in people with Type 1 diabetes
Rarely a first choice in patients with Type 2 diabetes
Useful for patients who require flexibility on a daily basis,
with irregular lifestyles, varied mealtimes or irregular eating
patterns or shift work
Offers optimum flexibility in terms of diet and activity Requires multiple insulin injections
Reduces the risk of hypoglycaemia More complicated to support and teach
Potential for better metabolic control if used optimally Requires more regular glucose testing
Closely mimics normal insulin physiology
Potential for the best control of basal and
postprandial hyperglycaemia
Potential for better weight management and lifestyle choice
Simple approach to transfer to basal bolus insulin therapy
If already taking once or twice daily basal insulin - continue this and simply add quick acting insulin or quick acting analogue before each
main meal
If taking premixed insulin, calculate how the present dose of pre-mixed insulin is divided into short and long acting, and use this to influence decision.
Or change to: See next page for options
Page 17
Change to: Option 1 Change to: Option 2
Basal bolus regimen with basal analogue (Glargine, Basal bolus regimen with twice daily intermediate
Detemir,Tresiba) insulin (Humulin I, Insuman basal, Insulatard)
Add up the total daily dose of the existing pre-mixed insulin Add total daily dose of premixed insulin. Usually take off 20%
regimen and then common practice is to reduce this dose by 20%
In some circumstances it may not be appropriate to take off
In some circumstances it may not be appropriate to take off 20%, (e.g. very poor glycaemic control or symptomatic of high
20%, (e.g. very poor glycaemic control or symptomatic of high blood glucose).
blood glucose)
Give 50% as basal insulin divided into two equal doses
Give 50% of the total daily dose as a basal insulin
Divide remainder to cover meals with quick acting insulin
Divide remainder to cover meals with a rapid acting insulin dependant on their eating habits
dependant on their eating habits
Example:
Example: Insuman Basal or Humulin I: 50 units am, 50 units pm.
Insuman Comb 25 or Humulin M3 50 units am, 50 units pm. Total daily dose = 100 units - 20% = 80 units.
Total daily dose = 100 units - 20% = 80 units. 50% of dose divided into two injections of intermediate insulin.
Give 40 units as basal insulin remainder given as 12 - 14 units of 20 units am and 20 units pm.
quick acting insulin with each meal dependant on eating habits. Remainder given as quick acting insulin with 12 - 14 units each
meal dependant on eating habits.
Titration of doses Indication for change of regimen
Adjust the basal insulin (long acting) to achieve Difficulty in giving multiple injections
satisfactory pre-breakfast blood glucose levels,
More regimented lifestyle, where patient does not
waiting 3 - 4 days between adjustments
require the flexibility
Although basal analogues are designed to work throughout
If post prandial blood glucose readings are raised consider
a 24 hour period, this may vary between 18 - 24 hours
using a basal plus regimen (See page 14)
If the insulin is taken in the morning consider that raised
fasting glucose levels may be due to inappropriate diet and
or the insulin running out rather than inadequate dosage 7
Also need to rule out nocturnal hypoglycaemia which can Your Record
manifest as raised fasting glucose levels My Diabetes Doctor / Nurse is:
Offer dietary advice on role of carbohydrates portion size,

Date HbA1c (your Target................ mmol/mol & %)
timing of meals and snacks
Target Caution Stop Review
Reduce the dose if blood glucose is too low during the night 48-59 mmol/mol 59-64 mmol/mol 75 + mmol/mol
(6.5%- 7.0%) (7.5%-8.0%) (9.0%-10%)
or pre-breakfast blood glucose result is 5mmol/l on more
than one occasion or < 4.5mmol/l on one occasion.
Adjust the short / rapid acting insulin to achieve satisfactory
blood glucose levels 2 hours after the meal or
before the next meal
leicestershirediabetes.org.uk

Lifestyle Factors
Section 3: Lifestyle Factors
Hypoglycaemia Weight Management
Hypoglycaemia Hypo is the most common side effect of insulin Generally people gain weight on insulin treatment mainly due to
treatment and impacts on an individuals well being, quality improved glycaemic control. Consider:
of life and lifestyle. (See page 21 & 22, for specific advice on Early discussion of the likelihood of weight gain
hypoglycaemia , prevention treatment and hypos and driving).
Discussion of weight management strategies
Referral to weight management clinic
Driving
If there is unexplained weight loss or gain, consider referral to
dietitian / specialist dietitian
Patients do not have to give up driving but do need to plan in
advance before getting behind the wheel.
Employment
The Law: Insulin users must inform the DVLA when
commenced on insulin - ensure the patient knows it is their
responsibility (www.dft.gov.uk/dvla) Diabetes is covered by the Disability Discrimination act 1995
Insurance- For your car insurance to be valid, you MUST inform Certain occupations are limited for those on insulin,
your insurance company as soon as you are diagnosed with e.g. Emergency services, Armed forces
diabetes. If your insurance company asks about diabetes you Shift patterns and activity levels will need to be considered
must tell them that you have it.
Further information is available from Diabetes UK Careline
Blood glucose levels should always be more than 6 mmol/l 0845 120 2960
(local guidance) the DVLA recommend 5 mmol/l, always test
before driving due to risk of hypos
Advise patient to carry easily accessible glucose treatments in
the car (e.g. Lucozade, glucose tablets) Alcohol
By Law individuals must inform the DVLA if they have had
more than one episode of disabling hypoglycaemia (requiring Government guidelines on alcohol intake are the same for
the assistance of another person) and be advised not to drive people on insulin as they are for those not on insulin
Give Safe Driving and DVLA leaflet (www. Alcoholic beverages have different effects on blood glucose
leicestershirediabetes.org.uk) levels
The risk of delayed hypoglycaemia needs to be discussed with
the patient
Monitoring
Where alcohol intake exceeds recommended levels, people need
appropriate advice to minimise risks.
Self Blood Glucose Monitoring (SBGM) is recommended in
people on insulin therapy Exercise
Those unable to perform SBGM may require more frequent
HbA1c testing- (See monitoring glycaemic control Physical activity is a key element in the prevention and
guidelines) management of Type 2 diabetes.
All people with Type 1 diabetes should be issued with ketostix Regular physical activity improves blood glucose control and
can positively affect lipids, blood pressure, cardiovascular
events, mortality, and quality of life
All types of activity including regular walks or gym workouts
will have an effect on glycaemic control
If the individual takes strenuous exercise and is insulin treated,
the dose of insulin may need to be reduced over the next 24
hour period
Exercise should be undertaken regularly to have continued
benefits. Most people with Type 2 diabetes can perform
Exercise safely (Practical Diabetes September 2013, Volume
30, Issue 7 - http://onlinelibrary.wiley.com/doi/10.1002/pdi.
v30.7/issuetoc)
See Exercise and Sports section on: www.leicestershirediabetes.org.
uk/611.html
Page 19
Lifestyle Factors
Travel Special occasions and cultural issues
Insulin use does not restrict travel opportunities, but planning is required Patients may need additional advice to manage these
situations, especially around feasting and fasting
Consider destination, climate, illness, time changes and zones,
Ramadan advice should be given 2 months before - if the
inactivity, mode of travel, availability and storage of supplies.
patient says they feel hypo at anytime during the fast, they
(See page 33)
should break the fast. Test blood glucose levels every 4 hours
Carry adequate identification. A supporting letter from a (Ref: Looking after diabetes during Ramadan: A guide for
healthcare professional on headed paper may be necessary patients www.leicestershirediabetes.org.uk)
Cultural awareness and sensitivity are essential
Healthy eating
Participation in events does not have to be restricted
Further information is available from:
Attention should be paid to the role of carbohydrate and insulin
action on blood glucose levels.
Diabetes UK website - www.diabetes.org.uk
Additional snacks are not automatically required and should
be tailored to the individuals needs Servier - 0753 662744
Care must be taken to ensure that advice given about
changing eating habits is not detrimental to the individuals
weight management goals Insulin and steroid use
Consider referring to the diabetes specialist dietitians
Steroid therapy is sometimes used in people with other long-term
conditions such as COPD and is frequently used in palliative care for
symptom control.
The impact of steroids is to increase blood glucose, which can

Some healthcare professional find it useful to compile a checklist cause additional hyperglycaemic symptoms
to document advice given when initiating and managing insulin. Once-daily steroid therapy taken in the morning tends to
An example of one can be found on the Leicestershire website: cause a late afternoon or early evening rise in glucose levels
www.leicestershirediabetes.org.uk which can be managed by isophane insulin
(e.g. Human Insulatard, Humulin I or Insuman Basal).
(Please see algorithm Appendix 3 for managing patients on once
daily steroid in end of life care)

Lifestyle Factors
Hypoglycaemia Hypos
Patients who are injecting insulin may be at risk of hypos.

Symptoms Hypos
A hypo is when blood glucose levels drop to Some individuals, particularly those with long duration diabetes and
below 4mmol/L / or persistent hypoglycaemia may not experience any symptoms.
Early signs and symptoms of a hypo include:
Some but not all patients will experience symptoms such as
sweating, palor, trembling and headaches but people with a long Sweating heavily
duration of diabetes may not have any symptoms of hypoglycaemia.
If early signs of hypoglycaemia are missed the symptoms may Feeling anxious
worsen and the individual may lose cognitive function. Trembling and shaking
Tingling of the lips
Hunger
Identifying those at risk Going pale
Palpitations
These include all insulin, Sulphonylurea (e.g. Gliclazide, Glipizide,
Glimepiride) and prandial regulator users (Nataglinide, Repaglinide) Symptoms may vary from person to person, particularly in the older
Other non - insulin therapies when added to a Sulphonylurea and / patient, symptoms include:
or insulin can increase the risk of hypoglycaemia Slurring of words
Patients who are at particularly high risk include those who also Behaving oddly
have one or more of the following: Being unusually aggressive or tearful
Having difficulty in concentrating
Poor appetite / erratic eating pattern
Weight loss
If the hypo is not treated at this stage, the person may
Renal deterioration become unconsciousness
Liver impairment/ carcinoma
Dementia
The elderly Hypos during End of Life
They may look pale, become confused, have behaviour change, Hypoglycaemia can be troublesome for individuals at any time and
become very drowsy, and lose consciousness. Sweating, fits, and particularly during end of life care. Every effort should be made to
skin colour change in a drowsy or unconscious person may be due avoid this side effect. (See Appendix 2 for glycaemic control during
to hypoglycaemia. end of life care)
Factors that should be considered at this time are:

Causes of Hypo
Do not aim for tight control in these individuals, blood glucose
reading between 6 - 15mmol/l are acceptable
A number of situations can cause a hypo, people particularly at risk
Aim for symptomatic relief
include those with:
Tailor insulin therapy to clinical needs
Impaired renal function
Rationalisation of glucose-lowering treatment for diabetes
Too much insulin
Specific glucose lowering therapies including SU, whether Involve an experienced community dietitian
used alone or in combination with other diabetes treatments Early identification of risk factors for hypoglycaemia
Delayed or missed meals or fasting Treat pain effectively
Eating less starchy foods than usual
Assess impact of weight loss
Unplanned or strenuous activity
Assess influence of nutritional deficits
Drinking too much alcohol or drinking alcohol without food
Sometimes there is no obvious cause, but treatment should always Assess influence of opiates / other pain killers on appetite
be carried out immediately, as advised. Consider community DSN support if appropriate
Do not assume if the patient is comatose that it is due to the end of
life primary condition.
Page 21
Hypos and driving
Hypos whilst driving Informing the DVLA
By Law Group 1 driver (car/motorcycle) who has had two or more

Complications with diabetes can affect ability to drive as well as risk
episodes of hypoglycaemia requiring assistance from another person
of hypos and accidents. See previous section on driving (page 19)
at any time (including when sleeping) in a year, must inform the
Blood glucose levels should always be more than 6 mmol/l DVLA, and be advised not to drive. In these cases the Licence willl
(local guidance), the DVLA recommend at least 5 mmol/l be withdrawn for 1 year following the first episode.
always test before driving due to risk of hypos whilst driving
By Law Group 2 driver (bus/lorry) with one or more episode(s) of
Plan for long journeys and take regular breaks and test 2 hourly hypoglycaemia requiring the assistance of another person in the
previous 12 months must inform the DVLA and be advised not to
Patient Advice: If you a have a hypo whilst driving
drive. They must also tell the DVLA if they or their medical team
1. Stop car as soon as possible feels you are at high risk of developing hypoglycaemia. www.
2. Remove keys dvla.gov.uk/dvla
3. Move to the passenger seat if safe
4. Treat the hypo
What are a doctors responsibilities?
Give patient Safe Driving and DVLA leaflet
Advise patient to carry easily accessible glucose When any doctor is aware that a patient is not fit to drive, they should
treatments in the car advise the person not to drive and to notify the DVLA. If a doctor
becomes aware that someone in their care does not notify the DVLA,
Advise patients not to drive for at least 45 minutes following or refuses to do so, the doctor is allowed under General Medical
a hypo Council guidelines to notify the DVLA. It would be good practice to
confirm this conversation in writing to the person concerned so that
there is no doubt about the advice. This should be documented in
the notes. The doctor may also want to inform the patient that their
insurance is no longer valid. It is up to the DVLA to revoke/renew a
licence. If the doctor has concerns but are not sure if the person is
fit to drive, they should advise the individual to notify the DVLA and
document this in the notes.

Treating Hypoglycaemia
Treating Hypoglycaemia Give one of the following: If after 5 minutes, the blood glucose level
150 ml of non-diet cola (small can) is still less than 4 mmol/l, repeat the
200 ml of pure smooth orange juice (small carton) treatment.
Is patient conscious and 100 ml of Lucozade Original
Yes
able to swallow? 4 glucotabs Once the blood glucose is above 4 mmol/l,
5 to 6 dextrose tablets give a starchy snack like a banana or glass
of milk or 2 biscuits unless a meal will be
eaten in the next 1 to 2 hours
No
Patients on PEG feeds: Repeat this procedure every 5 minutes

You should stop the feed and insert one of the until the blood glucose is above 4 mmol/l.
following;
Is patient conscious and Yes 30ml undiluted Ribena Afterwards resume the feed.
not able to swallow? 150 ml non-diet cola
100 ml Lucozade Original into the feeding tube.
Page 23
No
Once conscious (usually after about 10

If unconscious:
minutes), give one of the following:
Treating Hypos in the community
Put the patient in the recovery position and maintain airway - do not put glucose in the mouth. Give
1mg glucagon intra-muscularly if available and carer trained. 150ml non-diet cola
100ml Lucozade
If glucagon is not available or is ineffective, and IV access is available, give 75-80ml of 20% glucose (over 10-
15 minutes). If not available, call paramedics. Follow with a starchy snack such as a
Note: glucagon may not be effective in people with liver disease banana or 2 slices of bread.
After an episode of hypoglycaemia:

Review management plan with patient and relatives to clarify/confirm goals of diabetes management
Lifestyle Factors
Section 4: Managing Insulin During Illness in Type 1 and Type 2 Diabetes
Advice given to people with Type 2 diabetes for managing Insulin doses during illness
Person with diabetes treated with Insulin
Feeling unwell?
DONT STOP TAKING YOUR
INSULIN EVEN IF YOU ARE
UNABLE TO EAT.
Type 2 diabetes
Test blood glucose
Blood glucose less than 4 Blood glucose Blood glucose more than
No
mmol/L treat as hypo between 4 - 11 mmol/L 11 mmol/L
Yes
Take your insulin as normal Take carbohydrates as meal replacement and sip sugar-free
Take carbohydrates as meal replacement and sip sugar- liquids (at least 100ml/hour) if you are able
free liquids (at least 100ml/hour) if you are able. You You need food, insulin and fluids to avoid dehydration
need food, insulin and fluids to avoid dehydration and
serious complications and serious complications
Blood glucose Insulin dose*

11-17 mmol/L Add 2 extra units to each dose
17- 22 mmol/L Add 4 extra units to each dose
More than 22 mmol/L Add 6 extra units to each dose
*Take your prescribed insulin as above
Yes - Once you have given the initial increased dose contact your GP or Diabetes Specialist Nurse for advice if
repeat you still feel unsure about adjusting your insulin doses.
process If you are taking more than 50 units in total daily, you should double the adjustments. All
adjustments are incremental and should be reduced gradually as the illness subsides.
This algorithm has been adapted from insulin self adjustment advice for people on basal insulin
regimen. The Intermediate Diabetes Service, Enfield Community Services SEH-MHT, 2010.
Test blood glucose every 4-6 hours
Blood glucose Blood glucose Blood glucose less than 4

No
more than 11 mmol/L less than 11 mmol/L mmol/L treat as hypo
Yes
As your illness resolves, adjust your insulin dose back to normal

Version 3 30/11/2013 S.J.
Adapted from Trend- UK, MSD

Advice given to people with Type 1 diabetes for managing Insulin doses during illness If you
start vomiting,
are unable to keep fluids
Person with diabetes down or unable to control your
Feeling unwell? Type 1 diabetes blood glucose or ketone levels, you
treated with Insulin
must seek urgent medical advice.
DONT STOP TAKING YOUR
INSULIN EVEN IF YOU ARE
Test blood glucose and ketones UNABLE TO EAT.
Blood glucose more than 11 mmol/L and Blood glucose more than 11 mmol/L and Blood glucose less than 11 Take your insulin as normal
either no ketones or trace urine ketones. (Less ketones present (more than 1.5 mmol/L on mmol/L and no ketones Take carbohydrates as meal
than 1.5 mmol/L on blood ketone meter) blood ketone meter or +/++ on urine ketones) replacement and sip sugar-free
liquids (at least 100ml/hour) if
Blood glucose less than 4 you are able*
mmol/L treat as hypo
Take carbohydrates as meal replacement and sip sugar-free liquids (at least 100ml/hour) if you are able
*You need food, insulin and fluids to avoid dehydration and serious complications
Urine ketones + to ++ (1.5 - 3 Urine ketones + ++ to ++++ (more

Blood glucose Insulin dose* mmol/L on blood ketone meter) than 3 mmol/L on blood ketone meter)
11-17 mmol/L Add 2 extra units to each dose
Page 25
17- 22 mmol/L Add 4 extra units to each dose
More than 22 mmol/L Add 6 extra units to each dose Total daily Give an additional 10% Give an additional 20% of
Insulin dose of rapid acting or mixed rapid acting or mixed insulin
*Take your prescribed insulin as above
insulin every 4 hours every 2 hours
Once you have given the initial increased dose contact your GP or Diabetes Specialist
Nurse for advice if you still feel unsure about adjusting your insulin doses. If you are Up to 14 units 1 unit 2 units
taking more than 50 units in total daily, you should double the adjustments. All
15 - 24 units 2 units 4 units
adjustments are incremental and should be reduced gradually as the illness subsides.
This algorithm has been adapted from insulin self adjustment advice for people on basal insulin 25 - 34 units 3 units 6 units
Yes - regimen. The Intermediate Diabetes Service, Enfield Community Services SEH-MHT, 2010.
35 - 44 units 4 units 8 units
repeat
process 45 -54 units 5 unit 10 units
Test blood glucose every 4-6 hours If you take more than 54 units or if you are unsure how much to alter your dose, contact
your specialist team or GP. N.B. This algorithm has been adapted from DAFNE guidelines
Blood glucose Blood glucose Blood glucose less than 4 mmol/L Test blood glucose and Test blood glucose and
more than 11 mmol/L less than 11 mmol/L treat as hypo ketones every 4 hours ketones every 2 hours
Yes -
repeat
As your illness resolves, adjust your insulin dose back to normal No Blood glucose more than11mmol/L and ketones present? process
Version 2 25/11/2013
Managing Sick Days when on Insulin treatment
General Principles of Managing Sick Days
Introduction Sick days for Insulin pump users
When a person with diabetes is unwell, it is likely that their Insulin pump users can rapidly develop diabetic ketoacidosis (DKA) if
blood glucose levels will rise and the signs and symptoms of their insulin pump fails. If a persons blood glucose level rises rapidly
hyperglycaemia may still occur even if the person is not eating. they should:
If someone does not know how to manage their diabetes during Monitor for blood or urine ketones ( pump users are more
periods of illness, it can lead to other serious conditions such as likely to get euglycaemic ketosis)
diabetic ketoacidosis (DKA) in people with Type 1 diabetes and
Check the pump to ensure that it is working properly
hyperglycaemic hyperosmolar state (HHS) in those with Type 2
diabetes. The correct advice for care during inter-current illness may Check to see if the pump tubing is blocked or disconnected
prevent this happening.
Check that the cannula is in the correct place and is secure
All pump users should be advised to carry an insulin pen device
General principles of managing diabetes during with them containing quick-acting insulin that is in date for use in
inter-current illness emergencies. Insulin pump users will be under specialist diabetes
care and will have an emergency contact telephone number to use
should any issues arise. (Ref: TREND-UK career and competency
When managing a person with diabetes during inter-current illness
doc 3rd edition)
the aims are to:
Continue to manage the persons diabetes and blood glucose levels Sick pregnant women and children
Ensure the person receives sufficient carbohydrate intake
and address dehydration with fluid replacement. Seek urgent specialist advice / or admit
Test for and manage any ketones present in the body See pre-pregnancy planning a for women with diabetes and
Recognise whether the person requires additional Gestational diabetes antenatal care patient information leaflets on
medical attention www.leicestershirediabetes.org.uk
Food and fluid replacement
If the individual is unwell and unable to eat their usual meals, it is important that they continue to eat or drink some carbohydrate (starchy or
sugary foods) as a source of energy. The individual should try to take two to three servings from the list provided approximately four to five times a
day. They should also be encouraged to drink at least 4 - 6 pints (2.5 - 3.5 L) of sugar- free fluid in 24 hours (at least 100 mL each hour) in order to
avoid dehydration.
Table 2: Food Alternatives (UHL NHS Trust 2009)

Type of food alternative Amount*
Lucozade Energy 50 mL 2 fl oz glass
Fruit juice 100 mL 4 fl oz glass
Cola (NOT diet) +
100 mL 4 fl oz glass
Lemonade (NOT diet )+
150 - 200 mL 5 - 7 fl oz - 1 glass
Milk 200 mL 7 fl oz 1 glass
Soup+ 200 mL 7 fl oz 1 mug
Ice cream +
50 g 2 oz 1 large scoop
Complan
- - 3 level tsp (as a drink)
Drinking chocolate + - - 2 level tsp (as a drink)
Ovaltine or Horlicks - - 2 level tsp (as a drink)
* each serving provides approximately 10g of carbohydrate
However, if the individual starts vomiting or is unable to keep fluids down,
+
sugar quantities may vary widely according to brand
urgent medical advice should be immediately sought.
Ref: The reference is TREND-UK

Managing diabetes during intercurrent illness in the community (2013) www.diabetes.nhs.uk

Managing Sick Days when on Insulin treatment
Sick Day Management - T2DM
Specific advice on insulin management with or without combined use with glucose lowering therapies
Table 3
General recommendations for carers and healthcare professionals

Drug class
on the authors experience
General advice for all people with Blood glucose levels should be tested if a meter is available. If it is not available, be mindful of the
diabetes symptoms of hyperglycaemia.
The person should continue to take their medication while the blood glucose level is normal or high
unless they are feeling severely unwell (e.g. vomiting, diarrhoea or fever) or are dehydrated, in which
Biguanides (Metformin) case, Metformin should be temporarily stopped. The dose should be restarted once the person is
feeling better. Metformin should also be stopped in individuals where the severity of their illness
requires hospitalisation or confinement to bed.
Sulphonylureas (Glibenclamide, The person should continue to take their medication while the blood glucose level is normal or high.
Gliclazide, Glimepiride, Glipizide, If they are unable to eat or drink, they may be at risk of hypoglycaemia (low blood glucose levels) and
Tolbutamide) the medication may need to be reduced or stopped temporarily.
The person should continue to take their medication while the blood glucose level is normal or high.
Meglitinides (Nateglinide, Repaglinide) If they are unable to eat or drink, they may be at risk of hypoglycaemia (low blood glucose levels) and
the medication may need to be reduced or stopped temporarily.
The person should continue to take their medication while the blood glucose level is normal or high.
Thiazolidinediones (Pioglitazone) Medical advice should be sought if the person experiences unusual shortness of breath or localised
swelling as this may be a sign of possible heart failure, particularly in the elderly.
Glucagon-like peptide-1 (GLP-1)

receptor agonists.
The person should continue to take their medication while the blood glucose level is
(Exenatide extended release
normal or high. Medical advice should be sought if the person is vomiting, dehydrated or
(Bydureon) Exenatide (Byetta) twice
experiencing severe abdominal pain. Severe abdominal pain may indicate pancreatitis.
daily,Lixisenatide (Lyxumia),Liraglutide
once daily)
As this agent has only recently become available, the authors have limited clinical experience of
Sodium glucose co-transporter 2 using the drug during intercurrent illness recommend that readers refer to Summary of Product
(SGLT-2) inhibitors (Dapagliflozin) Characteristics . There is a risk of UTI and genital tract infection in people using SGLT-2s. Be aware of
postural hypotension particularly in the elderly.
Ref: adapted from TREND-UK Managing diabetes during intercurrent illness in the community (2013) www.diabetes.nhs.uk
Page 27
Section 5: Insulin Administration and Devices
Introduction Practical points for consideration
Insulin always has to be injected and so every device needs to be Having made the decision to start insulin the following points may
used with a needle. Sharps injuries are common and can affect influence choice of regimen and devices. The choice and type of
the user, carer or healthcare professional administering the insulin. delivery system used will depend on the individual persons:
The UK market supports patient choice with many different devices
available that can be used to administer insulin. These include: Preference
Manual dexterity
Insulin syringes
Visual capacity
Insulin pen devices
Insulin pumps Lifestyle
Type of insulin used to effectively treat their diabetes
As you know that there are over 20 different types of insulin. It Eating patterns
is therefore imperative that you choose and use the right type of Occupation
insulin and device.
Agreed frequency of injections
Having made the decision to start insulin the following points may Ability to grasp technique
influence choice of regimen and devices.
Choice may be influenced by availability of insulin (e.g. 10 ml vials
for use with syringe, 3ml cartridges for use with pens or pre-loaded
disposable pens, or the need for low volume insulin such as Insulin
Degludec, (U200) or Humulin R (U500) in those on high doses)
(See page 12)
Structured education
All patients should have been offered comprehensive structured

education programmes there is evidence that these programmes
are best delivered in groups and facilitate peer support
People with Type 2 diabetes should already have attended the

DESMOND Education Programme. If not please refer.
People with Type 1 diabetes, may benefit from attending
the DAFNE course which focusses on dose titration and
carbohydrate counting
Leicester City patients can refer to the Intermediate
Community Diabetes Service (ICDS insulin Management
Groups) for advice and support in dose titration of insulin for
both Type 1 and Type 2

Insulin Administration, Devices
Insulin delivery devices: Syringes
Syringes are suitable for people:
Who want to mix two insulins together in one device

Who inject high doses
Who want a back up device
Who require third party injections
Who need to be reassured by seeing the dose delivered
Using a vial of insulin and a syringe requires the user or their
carer to have good eyesight
Who have ability to read measurements on the syringe
Who have dexterity to withdraw the insulin from the vial
It is important that an insulin syringe is always used for insulin
injections as the use of an intramuscular injection syringe leads to a
risk of a 10 fold overdose of insulin.
In the UK, U100 insulin is mostly available for use in people with
Diabetes. This means that there are 100 units per 1ml of insulin.
U100 insulin syringes therefore provide the correct unit markings for Never draw up insulin with a syringe
U100 insulin. Insulin syringes always have a needle attached - these from a pen device or cartridge
come in different lengths. Other insulin strengths are available for
those requiring large doses. (see page 12)
Table 4: Insulin
12 INSULINS THE BALANCE GUIDE TO MEDS & KIT, 20112012 THE BALANCE GUIDE TO MEDS & KIT, 20112012 INSULIN 13
NAME MANUFACTURER SOURCE DELIVERY SYSTEM TAKEN ONSET, PEAK AND DURATION
Rapid-acting analogue 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
NovoRapid Novo Nordisk Analogue Vial, cartridge, prefilled pen Just before / with / just after food
Humalog Lilly Analogue Vial, cartridge, prefilled pen Just before / with / just after food
Apidra Sanofi-Aventis Analogue Vial, cartridge (two types), prefilled pen (two types) 015 mins before, or soon after, a meal
Short-acting / neutral
Actrapid Novo Nordisk Human Vial 30 mins before food
Humulin S Lilly Human Vial, cartridge 2045 mins before food
Hypurin Bovine Neutral Wockhardt UK Bovine Vial, cartridge 30 mins before food
Hypurin Porcine Neutral Wockhardt UK Porcine Vial, cartridge 30 mins before food
Insuman Rapid Sanofi-Aventis Human Cartridge, prefilled pen 1520 mins before food
Medium and long-acting

Insulatard Novo Nordisk Human Vial, cartridge, prefilled insulin doser As advised by your healthcare team
Humulin I Lilly Human Vial, cartridge, prefilled pen About 30 mins before food or bed
Hypurin Bovine Isophane Wockhardt UK Bovine Vial, cartridge As advised by your healthcare team
Hypurin Bovine Lente Wockhardt UK Bovine Vial As advised by your healthcare team
Hypurin Bovine PZI Wockhardt UK Bovine Vial As advised by your healthcare team
Hypurin Porcine Isophane Wockhardt UK Porcine Vial, cartridge As advised by your healthcare team
Insuman Basal Sanofi-Aventis Human Vial, cartridge, prefilled pen 4560 mins before food
Mixed
Humulin M3 Lilly Human Vial, cartridge, prefilled pen 2045 mins before food
Hypurin Porcine 30/70 Mix Wockhardt UK Porcine Vial, cartridge As advised by your healthcare team
Insuman Comb 15 Sanofi-Aventis Human Cartridge, prefilled pen 3045 mins before food
Insuman Comb 25 Sanofi-Aventis Human Vial, cartridge, prefilled pen (two types) 3045 mins before food
Insuman Comb 50 Sanofi-Aventis Human Cartridge, prefilled pen 2030 mins before food
Analogue mixture
Humalog Mix 25 Lilly Analogue Vial, cartridge, prefilled pen Just before / with / just after food
Humalog Mix 50 Lilly Analogue Cartridge, prefilled pen Just before / with / just after food
NovoMix 30 Novo Nordisk Analogue Cartridge, prefilled pen Just before / with / just after food
Long-acting analogue
Lantus Sanofi-Aventis Analogue Vial, cartridge (two types), prefilled pen (two types) Once a day, any time (but at same time each day)
Levemir Novo Nordisk Analogue Cartridge, prefilled pen, prefilled insulin doser Once or twice daily (at same time each day)
Insulin degludec U100 Novo Nordisk Analogue Pen cartridge touch pen duration Times are approximate and
may vary from person to person.
Insulin degludec U200 Novo Nordisk Analogue Insulin pen only (touch pen) onset peak
This is a guide only.
Ref: The Balance Guide to Med and Kitt 2011- 2012 Diabetes UK
Page 29
Types of Insulin Delivery Devices: Pumps
Insulin delivery devices: Insulin Pumps
Insulin pumps are usually recommended as a treatment by

consultants for patients with Type 1 diabetes. Pumps are the
most accurate, precise, and flexible insulin delivery system
currently available. In some pump users this tool can be
effective in optimising blood glucose control. An Insulin Pump
is a small programmable device that holds an insulin cartridge /
reservoir and delivers a continuous flow (basal rate) of insulin
Benefits
to the body through a thin plastic tube inserted in the body.
A pump is programmed to automatically deliver small pulses of

insulin over 24 hours to keep blood glucose in the desired ranges The benefits of using pump control in patients
between meals and overnight. Extra insulin is then given by the A pump can help patients avoid hyperglycaemia, (high blood
patient at the touch of a button to cover meal times. glucose) which in the long term can cause diabetic complications.
Most infusion sets are worn in the abdominal area and a tiny Fewer fluctuations in blood glucose levels during the course
flexible tube called a cannula is inserted easily into the skin. of the day
Patients generally refill their insulin reservoir and change their A person managing their diabetes with an insulin pump can more
infusion sets every 2 - 3 days. easily adapt their treatment to changes in their daily routine, for
example through travel or variable working hours, exercise
Less nocturnal hypoglycaemia, which in the long term can
cause diabetic complications
Pump therapy can also help prevent nocturnal hypoglycaemia
Improved long term control (HbA1c and weight)
Disadvantages
The pump may fail

The cannula may become blocked or disconnected
A supply of insulin pens should be kept just in case the pump fails
Who can use insulin pumps More expensive

Doesnt suit everyone
Insulin pumps can be used in children and adults
When a child under 12 is struggling with multiple daily Emergencies

injections insulin pump therapy maybe considered
If long term blood glucose levels (HbA1c) managed with All pump users should be advised to carry an insulin pen
multiple injections, continue to cause severe hypos device with them containing quick-acting insulin that is in
date for use in emergencies
HbA1c levels have remained high on multiple injection
therapy even after regular support from healthcare
professionals including NICE recommended Structured Specialist care
Education Programmes (i.e. DAFNE)
See NICE guidance http://www.nice.org.uk/TA151
Insulin pump users will be under specialist diabetes care and will have
an emergency contact telephone number to use should any issues arise.
(Ref: TREND-UK career and competency doc 3rd edition)
Diabetes Specialist Nurses specialising in Pump therapy are based

Insulin pump therapy is NOT generally recommended at the Leicester Royal Infirmary. Tel: 0116 258 5545
for patient with Type 2 diabetes

Types of Insulin Delivery Devices
Insulin delivery devices: Pens

Screw cap
Insulin pens are a very useful way to carry and administer

insulin. They allow users to administer insulin when they are
on the on the move or whenever it suits them
Push Cap
Insulin pens are either disposable one-shot devices or they
have replaceable cartridges of insulin
The tip of insulin pens include a fine, short needle and so users
can turn a dial to select the correct dosage
Insulin pen devices alleviate some user error in insulin
Insulin pens come in 2 types of delivery systems:
measurement and reduce the need for dexterity and good eyesight
a. Pre-filled pens which are disposed of when empty Some pens have a memory function so the user can be reminded as to
b. Pens where the insulin is given via a cartridge how much insulin they last took and when, (e.g. the NovoPen Echo)
The type of insulin cartridge used will determine the type of Some pens dial up in increments of 1 Unit and others in 2 Units
pen needed as different insulin manufacturers have different
fittings on their pen. (See example opposite) Children and young people can use pen devices that dial up in
0.5 Unit increments, (e.g. Luxura HD, NovoPen4, NovoPen
Junior Cartridges)
Be aware that different manufacturers use a different type of
cartridge and so their pens only take their make of insulin
Table 5: Insulin Pens Ref: The Balance Guide to Med and Kitt 2011- 2012 Diabetes UK
22 INSULIN PENS THE BALANCE GUIDE TO MEDS & KIT, 20112012 THE BALANCE GUIDE TO MEDS & KIT, 20112012 INSULIN PENS 23
MANUFACTURER NAME DOSAGE INSULIN USED IN PEN PEN NEEDLES USED APPEARANCE COLOUR MATERIAL CARTRIDGE REDIAL CARRYING CASE
(MINMAX) OR PREFILLED DOSE?
Eli Lilly KwikPen 160 units Humalog, Humalog Mix25, BD Micro-Fine +, Penfine universal click, Slate blue Plastic Prefilled Yes Soft case available
Humalog Mix50 Unifine Pentips from manufacturer
Humulin I 160 units Humulin I BD Micro-Fine +, Unifine Pentips Beige Plastic Prefilled Yes Soft case available
KwikPen from manufacturer
Humulin M3 160 units Humulin M3 BD Micro-Fine +, Unifine Pentips Beige Plastic Prefilled Yes Soft case available
KwikPen from manufacturer
HumaPen 160 units Lilly 3ml cartridges from Humalog BD Micro-Fine +, Penfine universal click, Burgundy or Metal Cartridge Yes Hard case, dark
Luxura and Humulin ranges Unifine Pentips champagne brown or burgundy
HumaPen 0.530 units Lilly 3ml cartridges from Humalog BD Micro-Fine +, Penfine universal click, Rainforest green Metal Cartridge Yes Hard case,
Luxura HD (12 -unit increments) and Humulin ranges Unifine Pentips burgundy
European Pharma InsuJet* 450 units All 3ml and 10ml UK None. Insulin administered by needle-free Green & white, Plastic Cartridge No Hard case with zipper
Group (EPG) insulin cartridges jet injections using compressed air through blue & white and steel
a precision nozzle or grey & white
Novo Nordisk FlexPen 160 units NovoRapid, Levemir, NovoMix 30 BD Micro-Fine +, NovoFine, NovoFine Autocover, Orange, green, Plastic Prefilled Yes Available from
Penfine universal click, Unifine Pentips or blue manufacturer
InnoLet 150 units Insulatard, Levemir BD Micro-Fine +, NovoFine, NovoFine Autocover, Cream Plastic Prefilled Yes None
Penfine universal click, Unifine Pentips
NovoPen 4 160 units All Novo Nordisk BD Micro-Fine +, NovoFine, NovoFine Autocover, Blue or silver Metal Cartridge Yes Novo blue
3ml penfill cartridges Penfine universal click, Unifine Pentips zip case
NovoPen 3 135 units All Novo Nordisk BD Micro-Fine +, NovoFine, NovoFine Autocover, Blue with Metal Cartridge Yes Soft pouch,
Demi (12-unit increments) 3ml penfill cartridges Penfine universal click, Unifine Pentips orange trim see manual dark blue
NovoPen 135 units All Novo Nordisk BD Micro-Fine +, NovoFine, NovoFine Autocover, Blue with green Metal Cartridge Yes Soft pouch,
Junior (12-unit increments) 3ml penfill cartridges Penfine universal click, Unifine Pentips or yellow trim see manual dark blue
PenMate A pen device that automatically inserts the needle when a button is pushed. Blue Plastic N/A N/A Soft pouch
Fits all Novo Nordisk half-unit pens.
Owen Mumford Autopen 121 units (green), Eli Lilly or Wockhardt UK BD Micro-Fine +, NovoFine, Penfine universal click, Green & white Plastic Cartridge No Soft pouch
Classic 3ml 242 units (blue) 3ml insulin cartridges Unifine Pentips or blue & white
Autopen 24 121 units (green), Sanofi-aventis BD Micro-Fine +, NovoFine, Penfine universal click, Green or blue Plastic Cartridge No Soft pouch
3ml 242 units (blue) 3ml insulin cartridges Unifine Pentips
Sanofi-Aventis SoloSTAR 180 units Lantus, Apidra, Insuman Comb 25 BD Micro-Fine +, Blue or grey Plastic Prefilled Yes Soft case available
Penfine universal click, Unifine Pentips or white from manufacturer
OptiSet** 240 units Insuman, Lantus, Apidra BD Micro-Fine +, White Plastic Prefilled No Soft case available
Penfine universal click, Unifine Pentips from manufacturer
ClikSTAR 180 units Insuman, Lantus, Apidra BD Micro-Fine +, Blue or silver Plastic Cartridge Yes Black zip case
Penfine universal click, Unifine Pentips
OptiClik** 180 units Lantus, Apidra BD Micro-Fine +, Dark blue or Plastic Cartridge Yes Hard case, blue
Penfine universal click, Unifine Pentips light grey
OptiPen Pro 1 160 units Insuman, Lantus, Apidra BD Micro-Fine +, Green or white Plastic Cartridge Yes Hard case,
** Penfine universal click, Unifine Pentips or steel pale blue
All pens take 3ml (300 units) cartridges. All pens available on prescription*, but not PenMate. BD Micro-Fine + Length: 4mm, 5mm, 8mm, 12.7mm. Gauge: 32G (4mm); 31G (5mm, 8mm); 29G (12.7mm) NovoFine Length: 6mm, 8mm,
* At the time of going to press, EPG was applying to get the InsuJet pen (which has replaced the SQ-PEN) available on prescription. 12mm. Gauge: 31G (6mm); 30G (8mm); 28G (12mm) NovoFine Autocover Length: 8mm. Gauge: 30G Penfine universal click Length: 6mm,
In the meantime, people who urgently need their InsuJet pen replaced or need consumables, and who would normally receive the device 8mm, 10mm, 12mm. Gauge: 31G (6mm, 8mm); 29G (10mm, 12mm) Unifine Pentips Length: 6mm, 8mm, 12mm. Gauge: 31G (6mm, 8mm);
on prescription, can receive it free of charge from the manufacturer. Contact EPG on +31 (0) 20 316 0140 or at info@nipholding.com. 29G (12mm).
** Sanofi-Aventis OptiSet, OptiClik and OptiPen Pro 1 pens will be discontinued from 31 December 2011.
Please note insulin Degludec (Tresiba) U100 and U200 is part of the Novo Nordisk range and comes in flex touch pens.
U100 comes with a pen and cartridge and U200 pen only
Page 31
Injecting Insulin
Injecting: Direct Subcutaneous
Direct subcutaneous insulin injection remains the most common form of

delivery, using a needle and syringe.
Insulin syringes are available in a number of needles lengths.
The capacity of the syringe should be chosen depending on

the dosage of insulin required
The markings down the side of the syringe shows how many
units of insulin are in the syringe
Injection sites
The most common injection site are the:
Stomach
Thigh
Buttocks Arms
Arms should be used with caution due to rapid onset of

(Diagrams kindly supplied by Beckton Dickinson Ltd) insulin action
Injection sites should be checked regularly
Injection sites should be checked regularly
Encourage the practice of rotating place if injecting

within a chosen site
Lipohypertrophy can effect the absorption of insulin and
Rotating injection sites may result in differing rates of lead to erratic glycaemic control -
absorption between sites and needs to be taken into if a patient stops using a lumpy injection site, blood
consideration, (e.g. insulin is absorbed more quickly glucose levels should be monitored closely as a reduction
from the abdomen than the thighs) in insulin may be required to avoid hypoglycaemia.

How to inject
Dial or draw up the correct dose of insulin as per chosen device

Remember to agitate insulin if required
Choose injection site (see diagram on opposite page)
No pinch required for 4mm, 5mm or 6mm needles
Pinch up subcutaneous fat for 8mm needles and above
(see diagram opposite)
Insert needle directly into raised area at 90o
Depress plunger or button to deliver insulin as per
manufacturers instructions
Hold needle in place for 10 seconds then remove
Change insulin pen needle every time they inject
Give patient the Safe use of insulin and you booklet and
passport/ insulin safety cards and discuss content with them
Storing insulins syringes, insulin pens and Cartridges
The pen currently being used can be kept at room temperature

for up to 4-8 weeks depending on the individual preparation
The insulin vial that is in current use may be kept at room
temperature for 28 days/ 1 month, insulin remaining in the
vial after this should be disposed of
Spare vials, pre-filled pens and cartridges that are not in use
can be stored in the fridge
Remember that between injections some insulin
Insulin is affected by extremes of temperature (i.e. very hot or particles separate and to ensure correct concentration /
freezing). Avoid keeping in contact with direct heat or sunlight consistency these Insulin needs to be mixed by inverting
or risk of freezing (e.g. in the hold of an aircraft). 20 times or rolling prior to injecting them.
Page 33
Section 6: Insulin Safety - Safe use of Insulin
Common Insulin Errors The Right Dose
Wrong syringe Insulin comes in vials for use with insulin syringes and pumps, in
Wrong insulin cartridges for insulin pens or pre-filled pens
Incorrect insulin name Each should be clearly labelled with the name of the insulin
Omitted doses Patient should be advised to keep a record of the amount of

insulin units they are taking
Use of U when prescribing insulin can lead to dose error
(see section The Right Dose opposite) There are 2 different designs of insulin cartridge so not all
cartridges can be used in all insulin pens. If the individual uses
Inaccurate transcription or documentation cartridges they need to know which pen is right and safe for
Inappropriate timing of injection or meals them to use
The incorrect insulin product was described in 2,201 incidents over Pre-filled pens should contain an individuals prescribed insulin
a six year period (NPSA)
Advise the individual to check the name of the insulin is correct
with their Pharmacist before they leave the pharmacy
The Right Insulin If insulin is prescribed using the letter U after the dose needed
instead of writing the word units in full, the U can be
mistaken for an 0. This can lead to a risk of you having an
There are over 20 different types of insulin. The packaging of insulin overdose of insulin. (e.g. 40 units instead of 4)
is often very similar and so are insulin names. This table shows
If someone else administers the individuals insulin always ask
some insulin names that are often confused:
them to check the dose
Humalog Mix 25 or
Humalog with
Humalog Mix 50
Humulin I or The Right Time
Humulin S with
Humulin M3
Humulin I or Healthcare professionals should discuss with patients when
Humalog with Humulin S or they need to take their insulin
Humulin M3
Advise patients if they are admitted to hospital and they are
NovoRapid with NovoMix 30 well enough: ask to keep insulin with them so they can self
Levemir with Lantus manage their diabetes - this is really important if an insulin
pump is used
Hypurin Porcine Hypurin Porcine
with Advise patients if they cant give or keep their own insulin,
Neutral 30 / 70 Mix
dont be afraid to ask staff when they need it
In 2010 the National Patient Safety Agency (NPSA) issued a

Rapid Response Report stating that:
A training programme should be put in place for

all healthcare professionals (including medical staff)
expected to prescribe, prepare and administer insulin
A free e- learning module on the safe use of insulin is

available at www.nhsiq.nhs.uk
Insulin passports help identify an individuals

prescribed Insulin details
Ref: Safe use of Insulin and you leaflet

Insulin Safety
The safe use of insulin and patient safety information
In 2011, the NPSA issued a 2nd Rapid Response Report stating that:
1. Adult patients on insulin therapy should receive a patient Storage and disposal
GP/Practice Nurse
Store unopened supplies of insulin in a refrigerator
information booklet and an Insulin Passport to help provide - it must not freeze
Insulin in use can be kept at room temperature
Diabetes
Useful Contacts
accurate identification of their current insulin products and
but avoid direct sunlight and heat e.g near
radiators, fires or window sills
Always dispose of needles into a sharps bin -
The safe use
of insulin
Insulin Safety
provide essential information across healthcare sectors. these are available on prescription
Make sure that you have enough supplies of
insulin - especially when you are going on holiday and you
Hypoglycaemia (Hypos)
2. When prescriptions of insulin are prescribed, dispensed or Hypoglycaemia is the main side effect of insulin
treatment. This can happen if your blood glucose levels Local Diabetes Helpline
administered, healthcare professionals should drop below 4 mmol/l. Early symptoms of hypos are:
Sweating heavily Hunger NHS Diabetes: www.diabetes.nhs.uk
cross-reference available information to confirm the correct

Anxiety Going pale Diabetes UK website: www.diabetes.org.uk
Trembling and shaking Palpitations
Tingling of the lips Dizziness
identity of insulin products How to avoid hypos:

Produced in cooperation with:
ABCD - Association of British Clinical Diabetologists

The Right insulin
The Right dose
Eat regularly Community Diabetes Consultant Forum The Right way
Keep to recommended alcohol limits and do not Diabetes Nurse Consultants Group The Right time
A shorter easy to read version of the NPSA information booklet is now

Diabetes UK - www.diabetes.org.uk
drink on an empty stomach DESMOND Diabetes Education Programme
Hypoglycaemia
Take your insulin at recommended doses and times DISN UK Group
Test before driving and do not drive if your blood IDOP - Institute of Diabetes for Older People
freely available and has been recommended by the NPSA for patient use. glucose is less than 5 mmol/l
Always carry glucose, snacks and your meter

National Patient Safety Agency
NHS Diabetes
Primary Care Diabetes Society
Patient Information
Booklet
(See opposite) This booklet has been translated in to 8 languages

You may need to reduce insulin doses before and TREND UK
after exercise The Royal College of Nursing Adapted from the National Patient Safety
University Hospitals of Leicester NHS Trust Agency, patient information booklet -
If you have a lot of hypos ask to see the Diabetes: Insulin, use it safely - in partnership
and is also available in large print on the Leicestershirediabetes.org.uk

Content by June James: University Hospitals of Leicester with National Diabetes Working Groups
specialist diabetes team. Design by Michael Bonar: www.desmond-project.org.uk
website: www.leicestershirediabetes.org.uk/583.html
Insulin Safety: Sharps
Safe Disposal of Sharps Sharps injury: the cost
Prescribe the patient a sharps disposal box Initial cost of a sharp injury is estimated as
1540 for Hepatitis B

There is national guidance for disposal of sharps (See www.
leicestershirediabetes.org.uk) guidance should include advice around : 235 For Hepatitis C
932 for HIV positive
Prescribing and disposal of sharps boxes
The psychological costs to the healthcare professional are not so
Do not dispose of sharps in general refuse to prevent needle
easily measured but can include:
stick injuries
Your CCG / prescribing lead will have local guidelines on Depression
sharps disposal
Anxiety, Inability to work
See New European guide for sharps - www.Fit4diabetes.com
Relationship problems
What should you do if you have a sharps injury?
Encourage the wound to gently bleed ideally whist holding it

under running water
Wash the wound using plenty of soap and running water
Dont scrub the wound
REMEMBER!
Dont suck the wound
Never re-sheath an insulin syringe or pen needle
Dry the wound and cover it with a waterproof plaster or
Never draw insulin from a pen cartridge or device
dressing
using a syringe
Seek urgent medical advice e.g. from Occupational Health
Always keep a sharps bin at the point of care
Always report the injury to your manager / employer
Page 35
Help and support
Supporting literature is available from: Supporting Documents
Leicestershire Diabetes Website - for healthcare professionals , Leicestershire Diabetes Website - for healthcare professionals ,
carers and people with diabetes carers and people with diabetes
www.leicestershirediabetes.org.uk Leicestershire diabetes guidelines
Diabetes UK
Tel: 0845 120 2960 www.TREND-UK.co.uk
website: www.diabetes.org.uk 4T Study Ref: Holman R et al 2009, NEJM 361:1736-1747
NovoCare Customer Care centre Safe Use of insulin - e learning access to the e-learning is
Tel: 0845 600 5055 either on the eUHL website or through www.nhsiq.nhs.uk
Website: www.novonordisk.co.uk Insulin passports www.nrls.npsa.nhs.uk/
Lilly Diabetes Care UK resources/?EntryId45=130397
Tel: 01256 315000 Driving and hypos leaflet www.leicestershirediabetes.org.uk
www.lilly.co.uk DVLA - www.dvla.gov.uk/dvla
Sanofi- Aventis Customer Service
Tel: 0845 606 6887

Appendix 1
Competency statements
5.8. iNjeCTAble TherApieS

For the safe administration and use of insulin and GLP-1 receptor agonists you should be able to:
1. Unregistered practitioner Describe the effect of insulin on blood glucose levels.
Be aware of local sharps disposal policy.
Show an understanding of the ongoing nature of the therapy.
Administer insulin competently where supported by local policy.
Report identified problems appropriately.
2. Competent nurse As 1, and:
Actively seek and participate in peer review of ones own practice.
Demonstrate a basic knowledge of insulin and GLP-1 receptor agonists (e.g. drug type, action, side-effects)
and administration devices used locally.
Demonstrate a high level of competency in the safe administration of insulin or GLP-1 receptor agonists.
Demonstrate and be able to teach the correct method of insulin or GLP-1 receptor agonist self-administration,
including:
Correct choice of needle type and length for the individual.
Appropriate use of lifted skin fold, where necessary.
Site rotation.
Storage of insulin.
Single use of needles.
Examine injection sites at least annually for detection of lipohypertrophy.
Identify correct reporting system for injectable therapy errors.
Complete the Safe use of insulin e-learning module (NHS Diabetes, 2010).
Describe circumstances in which insulin use might be initiated or altered and make appropriate referral.
Report concerns related to blood glucose or HbA1c results in a timely and appropriate fashion.
3. Experienced or As 2, and:
proficient nurse Demonstrate a broad knowledge of different insulin types (i.e. action, use in regimens).
Demonstrate a broad knowledge of GLP-1 receptor agonists (e.g. drug type, action, side-effects).
Assess individual patients self-management and educational needs and meet these needs or make
appropriate referral.
Support and encourage self-management wherever appropriate.
Initiate insulin or GLP-1 receptor agonist therapy where clinically appropriate.
Recognise when injection therapy needs to be adjusted.
Recognise the potential psychological impact of insulin or GLP-1 receptor agonist therapies and offer
support to the person with diabetes or their carer.
Recognise signs of needle fear/needle phobia and offer strategies to help manage this.
16 An Integrated Career and Competency Framework for Diabetes Nursing
Page 37
Appendix 2
End of Life Diabetes Management - Algorithm for Glycaemic Control

End of Life Diabetes Management
Discuss changing the approach to diabetes management with patient and/or family if
not already explored. If the patient remains on insulin ensure the diabetes specialist
nurses (DSNs) are involved and agree monitoring strategy.
Type 2 diabetes Type 2 diabetes on other

Type 1 diabetes always
Diet controlled or tablets and/or insulin /
on insulin
Metformin treated or GLP1 Agonist#
Stop tablets and GLP1 Continue once daily

Stop monitoring injections morning dose of insulin
blood sugars Consider stopping insulin Glargine (Lantus) with
depending on dose reduction in dose
If insulin stopped: If insulin to continue: Check blood glucose

Urinalysis for Prescribe once once a day at teatime:
glucose daily - If daily morning If below 8 mmols/l
over 2+ check dose of isophane reduce insulin by
capillary blood insulin^ or long 10-20%
glucose acting insulin If above 20 mmols/l
If blood glucose Glargine (Lantus) increase insulin by
over 20 mmols/l based on 25% less 10-20% to reduce
give 6 units rapid than total previous risk of symptoms or
acting insulin * daily insulin dose ketosis
Recheck capillary
blood glucose after
2 hours
If patient requires rapid

acting insulin* more
than twice consider daily
isophane insulin^ or
Glargine (Lantus)
Key Keep tests to a minimum. It may be necessary to perform some tests to ensure
unpleasant symptoms do not occur due to low or high blood glucose.
#
Bydureon (Exenatide ER) Byetta
(Exenatide) /Victoza, (Liraglutide),
It is difficult to identify symptoms due to hypo or hyperglycaemia in a
Lyxumia (Lixisenatide) dying patient.
If symptoms are observed it could be due to abnormal blood glucose levels.
* Humalog/Novorapid/Apidra
^ Humulin I /Insulatard/ Test urine or blood for glucose if the patient is symptomatic
Insuman Basal Observe for symptoms in previously insulin treated patient where insulin has
been discontinued.
For queries relating to the diabetes flowchart please contact the Diabetes Specialist Nurses
For queries relating to palliative care please contact the Palliative Care Team
Version 6, 26/11/2013 S.Jamal

Appendix 3
End of Life Diabetes Management - Managing Glucose Control on Once Daily Steroids
No known diabetes
Check random glucose before starting on steroids to identify patients at risk
Random capillary blood glucose over 8 mmol/l needs further checking with venous blood
Random venous glucose over 7.8 mmol/l means at risk of developing diabetes with steroid therapy
Random venous glucose over 11 mmol/l needs a second check to confirm pre-existing unknown diabetes
Known Diabetes
Reassess glucose control and current therapy
Diet controlled or
Sulphonylurea treated
Metformin alone or Insulin controlled
(Gliclazide)
Metformin + Gliptin
Test before evening If no hypoglycaemia Twice daily insulin Basal bolus insulin
mealtime symptoms, day or night and Morning dose will Breakfast & lunchtime
If develops repeated taking less than 320mg/day need to increase rapid acting insulin may
high readings (urine Adjust balance of twice according to glucose need to increase to avoid
glucose>2+ or blood daily doses of Gliclazide reading before high readings before
glucose >15mmol/l) by giving up to a max evening meal lunch or evening meal
add Gliclazide 40mg 240mg in morning dose Aim blood glucose Aim blood glucose 6-15
with breakfast plus 80mg pm) 6-15 mmol/l before mmol/l before lunch
Increase morning evening meal unless and evening meal unless
Aim blood glucose 6-15
dose by 40mg patient has hypo patient has hypo before
mmol/l or <1+ glycosuria
increments before meals despite meals despite mid-meal
before evening meal
Aim blood glucose mid-meal snacks snacks or has long gaps
6-15mmols/l or <1+ between meals
trace glycosuria
before evening meal
If no hypoglycaemia symptoms, If glucose above 15 If glucose above 15 mmol/l

day or night and taking full mmol/l before evening before lunch or evening meal
dose 320mg/day meal Increase breakfast or
If no hypoglycaemia Increase dose lunchtime dose
Switch to morning
symptoms, day or night, Review daily until Review daily until stable
Insulatard, Humulin I or
taking 240mg and still stable increasing increasing dose as
Insuman Basal 10 units on
above target dose as necessary necessary
first day of steroids
Consider adding Aim blood glucose 6-15 If glucose 10 - 15 mmol/l If glucose 10 - 15 mmol/l
evening meal dose mmol/l before evening meal before evening meal before lunch or evening meal
of Gliclazide or Consider increasing Consider increasing
move to morning dose depending on breakfast or lunchtime
insulin risk of hypoglycaemia dose depending on risk
Review daily until of hypoglycaemia
If glucose above 15 mmol/l stable increasing Review daily until stable
before evening meal dose as necessary increasing dose as
Increase dose by 4 units necessary
Review daily until stable
increasing dose as necessary
If glucose 10 - 15 mmol/l
before evening meal Assuming no hypoglycaemia, pre meal time glucose is
Consider increasing dose above 10mmol/l and increase in dose is needed
depending on risk of Increase dose by 2-5 units if dose below 20 units
hypoglycaemia overnight Increase dose by 5-10 units if dose 20-50 units
Review daily until stable Increase dose by 10-20 units if dose 50-100 units
increasing dose as necessary Review daily until stable increasing dose as necessary
If steroids are reduced or discontinued: review any changes made and consider reverting to previous therapy or doses
If unsure at any stage about next steps or want specific advice on how to meet with patients needs or expectations
please contact the Diabetes Specialist Team
Version 2 10th July 2012 sj
Page 39
Leicestershire Diabetes Guidelines for Insulin Initiation 2013

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Endorsed by Leicestershire Medicines Strategy Group

These guidelines are designed for use by those trained

June James - Nurse Consultant in Diabetes

Date of Preparation: 25th November 2013

www.leicestershirediabetes.org.uk 2013 Page 2

Appendix 1: TREND-UK competency document 37

There are 3 million people with diabetes in the United Kingdom

www.leicestershirediabetes.org.uk 2013 Page 4

Indications for Insulin Initiation and Management in Adults

Consider starting insulin in

Where and when to initiate insulin Allaying fears of starting insulin

Glucose Lowering Therapies Algorithm

Figure1 Ref: Leicestershirediabetes Guidelines 2012

Glucose Lowering Therapies - Algorithm for T2DM

HbA1c > 48mmol/mol (6.5%) Consider Sulphonylurea here if:

Increase insulin dose and intensify regimen

Glucagon-Like Peptide-1 receptor agonists (GLP-1 agonists)

www.leicestershirediabetes.org.uk 2013 Page 6

Use of Oral and Non - Insulin Therapies in Combination with Insulin

The individuals lifestyle consider:

Use of Oral and Non - Insulin Therapies in Combination with Insulin

Oral and Non - insulin

DPP-4Is licensed for use with Insulin are: Sitagliptin (Januvia),

Acarbose Not recommended in combination with Insulin

Sodium glucose co-transporter 2 inhibitors (SGLT-2 inhibitors)

www.leicestershirediabetes.org.uk 2013 Page 8

Section 1: Introduction to Insulin

Short acting Long acting

Rapid acting insulin analogues:

Short acting non- analogue insulins:

Intermediate acting insulin:

Targets of therapy T2DM Titrating doses - key principles

Review trends in capillary blood glucose (CBG) readings rather

Rapid-acting Insulin Action e.g. NovoRapid , Humalog, Apidra

Peak: 0.5-1.5 hours

Duration: 6-8 hours

Intermediate-acting insulin Action e.g. Humulin I, Human Insulatard, Insuman Basal

Onset: 2-4 hours

! Re-suspension of intermediate acting insulin is critical. If this is not done

Long-acting Insulin Action e.g. Glargine (Lantus), DetemirLong

Duration: 18-42 hours

- please refer to the manufacturers guidance for individual products. Insulin

www.leicestershirediabetes.org.uk 2013 Page 10

Example of Insulin Regimens

Insulin Regimen: Basal Bolus e.g. Intermediate and short acting

non-analogue intermediate Long acting Insulin

8am 12pm 6pm 8pm

Insulin Regimen: Twice daily pre - mixed insulin

Pre-mixed human soluble/isophane:

Rapid acting Short acting

The peak of action varies with individual products

Different Insulin Formulation and Concentration

U100 strength insulin is the preparation most commonly used

This product is not licensed in the UK but is still

Always check that the correct strength of

www.leicestershirediabetes.org.uk 2013 Page 12

Section 2: Potential Insulin Regimens for Type 2 Diabetes:

Basal insulin with Oral Hypoglycaemic agents

Once-daily basal insulin in combination with oral hypoglycaemic agent

Simple approach to initiation of Insulin therapy