diabetes - insulin initiation - insulin initiation ... · pdf filethese guidelines are...
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these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation - University Hospitals of LeicesterNHS Trust
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation - background information (1) University Hospitals of LeicesterNHS Trust
Working in partnership with PCTs across Leicestershire and Rutland
indications for insulin:•NewlyDiagnosedType1Diabetes
•Allpreviousattemptstoachievedesiredtargethavefailedi.e.lifestylemeasures,maximumoraltherapy
•PersistentfailuretoachievedesiredHbA1c
•Patientsymptomatic,i.e.weightloss,lethargy
• Type2Diabeteswhereearlyinsulinisindicated(seeGlycaemicManagementGuidelines)
•SteroidinducedDiabetes
•GestationalDiabetes
•Postacutemyocardialinfarction
• Intolerancetooralagents
•Moresuitabletopatientslifestyle
•Acuteneuropathiessuchasproximalamytrophy
logistics for insulin initiation:• Identifydedicatedtimebycompetenthealthcare
professional for initiation and follow up.
•OnetooneconsultationsorGroupsessions.
• Identifyandagreethemostappropriateinsulinregimes(seeInsulinInititiation-IndicationsforInsulinandPotentialRegimens).
•Makesureappropriateequipmentandeducationalmaterialisavailable.
• Identifyappropriateenvironment.
•Provideongoingsupportandcontactdetails.
principles of good practice:• InType2Diabetestheissueofinsulinshouldbediscussedearlyoninthediagnosis.
• InType2Diabetesthinkaboutinsulinearly,i.e.whenHbA1cisprogressivelyrisingandisconsistentlyabove>7.4%andmaximumtoleratedoraltherapyandlifestylechangesareinplace.
• InType1Diabetesstartinsulinwithin24hours.
• Thewayinwhichthesubjectisapproachedshouldbesensitivetothepersonsneeds.
•Thedecisiontostartinsulinshouldbedoneinagreementandpartnershipandthechoiceofregimetailoredtotheindividual’s needs.
• Insulininitiationshouldbepartofastructuredcareplanandeducationalprogramme.
•Thepersonshouldagreetoandunderstandthebenefitsofinsulin;inadditiontheyshouldalsounderstandtheimplicationofinsulin(seeSupportingInformation(1)and(2)).
•Thepersoninitiatinginsulinshouldbetrainedandcompetent.
• InGestationalDiabetesinsulinshouldbemanagedbythesecondarycareteam.(SeeReferralCriteriatoSpecialistServices.)tel: lri - 0116 258 6403: lgh - 0116 258 4855.
•Thereshouldbeprovisionforadequatestructuredfollowup.
•Accesstoappropriatedietaryadviceisessential.
•Animalinsulinsarenotrecommendedfornewinsulinstarts.
key principles• ManypatientswithType2diabeteswillrequireinsulin
therapy.IntheUKPDSover50%ofpatientsby6yearsrequiredadditionalinsulintherapy.
• InitiationofinsulintherapyinType2diabetesstillremainsmoreofanartthanascienceatthepresenttime,andthisareacreatesmuchconfusion.
• ItisimpossibletoproducesimpleguidelinesapplicableforeverypatientwithType2diabetesforinsulininitiation.Thereis no clear evidence to suggest that any particular approach hassignificantadvantagesoverandaboveanalternativeapproach.
• InnormalandoverweightpatientswithType2diabetes,Metformintherapyshouldbecontinuedatthemaximumtolerateddose,aslongasthereisnocontra-indication,e.g.eGFR<30ml/min(donotinitiateifeGFR<45ml/min),unstableheartfailure.(ItisimportanttocheckthatthepersonhasnosymptomsofintoleranceofMetformintherapy.)
potential barriers to starting insulin:•Occupationalissues
(SeeInsulinInitiation-SupportingInformation1).
•Fearofinjections
•Fearofhypoglycaemia
•Fearofweightgain
SupportfromDSNsinthecommunityandUHLisavailableonrequest(seeDiabetesGuidelines).
Accreditedinsulinmanagementtrainingisavailablelocally.Visit www.leicestershirediabetes.org.uk
for more information
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation - University Hospitals of LeicesterNHS Trust
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation - background information (2)Working in partnership with PCTs across Leicestershire and Rutland
Insu
lina
ctiv
ity0 2 4 6 8 10 12 14 16 18 20 22 24
Soluble Human Insulin: Actrapid, Humulin S
Onset: 30minsPeak: 2-4hoursDuration: 6-8hours
Insu
lina
ctiv
ity
0 2 4 6 8 10 12 14 16 18 20 22 24
Rapid Acting Insulin Analogue: Novorapid Aspart, Humalog Lispro, Apidra
Onset: 0-15minsPeak: 1-2hoursDuration: 3-5hours
Insu
lina
ctiv
ity
0 2 4 6 8 10 12 14 16 18 20 22 24
Intermediate Human Isophane Insulin’s: Insulatard, Humulin I
Onset: -Peak: 4-8hoursDuration: 14-16hours
Insu
lina
ctiv
ity
0 2 4 6 8 10 12 14 16 18 20 22 24
Long Acting Basal Analogues: Glargine (Lantus), Detemir (Levemir)
Onset: ~2hoursPeak: NoneDuration: 18-24hours
Insu
lina
ctiv
ity
0 2 4 6 8 10 12 14 16 18 20 22 24
Pre-mixed Human Soluble/Isophane: Mixtard 30, Humulin M3 etc
Onset: SeeabovePeak: SeeaboveDuration: SeeaboveMixtard30,M3refersto%of solubleinsulinie.30%Soluble 70%Isophane
Insu
lina
ctiv
ity
0 2 4 6 8 10 12 14 16 18 20 22 24
Pre-mixed Analogues/Isophane: Novo Mix 30, Humalog Mix50, Mix25
Onset: SeeabovePeak: SeeaboveDuration: SeeaboveNovoMix30,HumalogMix50/Mix25refersto%ofrapidacting analogue insulin
oVerView of insulin and actions
animal insulinsSomepatientsonanimalinsulinsareadequatelycontrolledanddonotrequireachangeininsulinregimen.
Indications for changing to Human or Analogue Insulin regime:
•Poororerraticcontrol
•Problemswithhypoglycaemia
•Patientchoice
•Failuretoreachglucosetargets
•Useofdevices
•Problemsatinjectionsites
Whenchangingfromanimaltoanalternativeinsulina20%reductionindoseisrecommended,initiallytheywillrequireweeklyreviewofmonitoring.Maywishtoseek specialist advice.
NB:Rarely,somepatientswhopreviouslychangedfromanimaltohumaninsulinmayexperiencedifficultieswithhypoglycaemiaandprefertorevertbacktoanimalinsulin.ThisshouldbediscussedwiththeSpecialistTeamonanindividualbasis.
• InrelationtocombinationwithinsulininType2Diabetesonly: Biguanides: Metformin.
Evidence support combination with insulin due to benefits in weight management, glycaemic control and CHD risk.
• Sulphonylureas,InsulinSecretagogues,PrandialGlucoseRegulators(Nateglinide,Repaglinide) Generally are discontinued when commencing insulin. Evidence supports some combinations (See Insulin Initiation - Detailed Guide). Usually continue if using once daily basal analogue and regularly review dose.
• Glitazones:Pioglitazone,Rosiglitazone. Usually discontinue when insulin commenced. Now licensed for use with insulin in specific circumstances - discuss with specialist team.
• Acarbose:In our practice we do not use in combination with insulin although there is some evidence to support this.
oVerView of the use of oral hypoglycaemic agents in combination with insulin:(fordetaileddescriptionseeDiabetesManagement-OralAgents).
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - insulin initiation - supporting information (1)
hypoglycaemia
driVing
monitoring
employment
weight management
healthy eating
coping with illness
hypoglycaemiaKeypointstoconsider:
•Peopleworryaboutit.
•Needtoidentifysymptoms,potentialcausesandtreatment.
•Prevention.
•Whentoseekhelp.
driVingKeypointstoconsider:
•Riskofhypoglycaemia.
•Lossoflivelihood.
• ImplicationsforinsuranceandDVLA.
Ensure individual understands their responsibilitiesintermsofsafety.See Diabetes UK information.
monitoring•Selfbloodglucosemonitoring(SBGM)usually
recommended.
•ThoseunabletoSBGMmayfindurinetestinghelpfulandmayrequiremorefrequentHbAICmeasurement.Seemonitoringglycaemiccontrolguidelines.
employment•DiabetesiscoveredbytheDisabilityDiscrimination
Act1995.
•Certainoccupationsarelimitedforthoseoninsulin,e.g.EmergencyServices,Forces.ContactDiabetesUKCarelineformoredetails.
•Shiftpatternsandactivitylevelswillneedtobeconsidered.
FurtherinformationisavailablefromDiabetesUKCareline: 0207 4241000.
coping with illness• Insulindosesmayneedadjustingduringillness.
•Patientsmayrequireadditionalsupport.
•Morefrequentmonitoringmayberequired.
•GenerallyinsulinshouldneverbestoppedinType2Diabetes.
type 1 diabetes• Insulinshouldneverbestoppedasthereisarisk
of ketoacidosis.
•Patientsshouldtesturineorbloodforketonestoidentify risk of ketoacidosis.
•Theymayrequirespecialistadvice.
weight managementGenerallypeoplegainweightoninsulintreatmentmainlyduetoimprovedglycaemiccontrol. Consider:
•Earlydiscussionofappropriateweightforindividual.
•Discussionofweightmanagementstrategies.
•Unexplainedweightlossorgain,considerreferralfor specialist advice.
healthy eating•Theneedforahealthydietisnotaffectedby
insulin initiation.
•Additionalsnacksarenotautomaticallyrequiredandshouldbetailoredtotheindividualsneeds.
•Caremustbetakentoensurethatadvicegivenaboutchangingeatinghabitsisnotdetrimentaltotheindividual’sweightmanagementgoals.
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation -Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - insulin initiation - supporting information (2)
exercise
alcohol
traVel
special occasions and cultural issues
on going care
help and support
exercise•Mostpeoplewouldbenefitfromincreasing
physical activity levels.
•Caremustbetakentoavoidhypoglycaemia.
•Someinsulinregimesmaybemoresuitableforpeople with active or varied lifestyles.
•Mostsportsarepossibleforpeopleoninsulin,howeverthereareafewexceptionseg.deepseadiving,free-fallparachuting.
Alltypesofactivityhaveaneffectonglycaemiccontrol.
alcohol•Governmentguidelinesonalcoholintakearethe
sameforpeopleoninsulin.
•Alcoholbeverageshavedifferenteffectsonbloodglucose levels.
•Theriskofdelayedhypoglycaemianeedstobediscussed.
•Wherealcoholicintakeexceedsrecommendedlevels,peopleneedappropriateadvicetominimiserisks.
traVel• Insulindoesnotrestricttravelopportunities,
butplanningisrequired.
•Considerdestination,climate,illness,changeinactivity,modeoftravel,availabilityandstorageofsupplies.
•Carryadequateidentification.Asupportingletterfromahealthcareprofessionalonheadedpapermaybenecessary.
help and supportSupporting literature available from:LeicestershireDiabetesWebsite-forhealthcareprofessionalsandpeoplewithdiabetes. www.leicestershirediabetes.org.uk
DiabetesUK tel: 0207 424 1000 Websitewww.diabetes.org.uk
NovoCareCustomerCareCentre tel: 0845 600 5055 Website:www.novonordisk.co.uk
LillyDiabetesCareUK tel: 01256 315000 Website:www.lilly.co.uk
Sanofi-AventisCustomerServices tel: 0845 606 6887
special occasions and cultural issues•Patientsmayneedadditionaladvicetomanage
thesesituations,especiallyaroundfeastingandfasting
•Culturalawarenessandsensitivityareessential.
•Participationineventsdoesnothavetoberestricted.
Furtherinformationisavailablefrom: •www.leicestershirediabetes.org.uk •DiabetesUKWebsite-www.diabetes.org.uk •Servier-01753662744.
ongoing care•Regularfollowupisrequiredtailoredandagreed
with the individual.
•Requirementsmaychangeovertime.
•Careshouldbepatientcentred.
•Educationshouldsupportselfmanagementskills.
Some health care professionals find it useful to compile a checklist to document advice given
wheninitiatingandmanaginginsulin.Anexample of one can be found on the
LeicestershireDiabeteswebsite-www.leicestershirediabetes.org.uk
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - insulin administration and deVices (1)
points for considerationHavingmadethedecisiontocommenceInsulin(SeeInsulinInitiation-BackgroundInformationsheet)thefollowingpointsmayinfluencechoiceofregimeanddevices:•Dexterity•Vision•Eatingpatterns•Lifestyle•Occupation•Agreedfrequencyofinjections•Abilitytograsp
techniques
NB:Choicemaybeinfluencedbyavailableformatofinsulin,eg.10mlvialsforusewithsyringes,3mlcartridges for use with pens or preloadeddisposablepensetc.
list of leaflets aVailableLeicestershire Diabetes Websitewww.leicestershirediabetes.org.uk
Diabetes-TheWaytoGoodNutritionLeicestershireNutrition&DieteticService
UHL Diabetes Department-leaflets•LRI-0116 258 5545•LGH-0116 258 8249
Diabetes and Insulin LeafletsonallaspectsofDiabetesandInsulin
Novo Nordisk-0845 600 5055Lilly-01256 315 999Sanofi-Aventis -0845 606 6887
how to inject•DialordrawupcorrectdoseofInsulinasperchosen
device.
•RemembertoagitateInsulinifrequired.
•Chooseinjectionsite(seepicture).
•Pinchupsubcutaneousfatfor8mmandaboveneedles(nopinchuprequiredfor5mmx6mmneedles).
• Insertneedledirectlyintoraisedarea.
•DepressplungerorbuttontodeliverInsulinaspermanufacturersinstructions.
•Holdneedleinplacefor10secondsthenremoveneedlefromarea.
sharp disposalThereisnationalguidancefordisposalofsharps.Seewww.leicestershirediabetes.org.uk.Guidanceshouldinclude advice around:•Useofsafeclipdeviceasaneedleclipper.
• Issueanddisposalofsharpsboxesoralternativecontainerstomeetindividualsneeds.
•Avoidanceofdisposalofsharpsingeneralrefusetopreventneedlestickinjuriesetc.
YourPCTwillhavelocalguidelinesonsharpdisposal.
pen deVices•SpareInsulincartridges/pre-filledpen-keepinfridge.
•Pencurrentlybeingusedcanbekeptatroomtemperatureforupto1month.
syringes•SpareInsulinvialsshouldbekeptinthefridge.
•TheInsulinvialthatisincurrentusemaybekeptatroomtemperatureforupto1month,Insulinremaininginvialafterthislengthoftimeshouldbedisposedof.
points to rememberInsulinisaffectedbyextremesoftemperaturei.e.veryhotorfreezing.Avoidkeepingincontactwithdirectheatorsunlightor risk of freezing e.g. in the hold of an aircraft.
•REMEMBERthatbetweeninjectionssomeInsulinparticlesseparateandtoensurecorrectconcentration/consistencytheseInsulinsneedtobemixedbyinverting20timespriortoinjectingthem.
storage of insulin
• Injectionsitesshouldbecheckedregularly.LipohypertrophycaneffecttheabsorptionofInsulin-ifapatientstopsusinga"lumpy"injectionsitebloodglucoselevelsshouldbemonitoredcloselyasareductioninInsulinmayberequiredtoavoidhypoglycaemia.
•Buttockscanalsobeused.Armsshouldbeusedwithcaution due to rapid onset of action.
•Encouragethepracticeofrotatingplaceifinjectingwithina chosen site.
•Rotatinginjectionsitesmayresultindifferingratesofabsorptionbetweensitesandneedstobetakenintoconsideration,eg.insulinisabsorbedmorequicklyfromtheabdomenthanthethighs.
injection sites
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin administration and deVices (2)
Date of preparation: May 2008. For review: May 2010.
Working in partnership with PCTs across Leicestershire and Rutland
Company&PenName InsulinUsed Min-Max Cartridge Reusableor On Dose Size Pre-filled Prescription
noVo nordisk Novopen3Classic AlltypesNovoNordisk 1-70units 300units(3ml) Reusable Yes insulinPenfill3mlcartridge NovopenJunior AlltypesNovoNordisk 0.5-35units 300units(3ml) Reusable Yes insulinPenfill3mlcartridge (0.5unitdosing)
Novopen3Fun AlltypesNovoNordisk 1-70units 300units(3ml) Reusable Yes insulinPenfill3mlcartridge Flexpens Detemir,Novorapid 2-70units 300units(3ml) Prefilled Yes andNovomix30 Innolet Insulatard,Mixtard30 1-50units 300units(3ml) Prefilled Yes
lilly HumapenLuxura Lilly3mlcartridges 1-60units 300units(3ml) Reusable Yes HumapenLuxuraHD Lilly3mlcartridges 0.5-30units 300units(3ml) Reusable Yes (0.5unitdosing)
Lillyprefilledpen LillyPrefilledRange 1-60units 300units(3ml) Prefilled Yes Humajectprefilledpen LillyHumajectRange 2-96units 300units(3ml) Prefilled Yes
sanofi-aVentis OptiPenPro1 InsumanRange 1-60units 300units(3ml) Prefilled Yes Opticlik LantusandApidra 1-80units 300units(3ml) Reusable Yes Optiset Lantus,Apidra&InsumanRange 1-42units 300units(3ml) Prefilled Yes Solostar LantusandApidra 1-80units 300units(3ml) Prefilled Yes AventisOptiset InsumanRange&Lantus 2-40units 300units(3ml) Prefilled Yes Autopen24 LantusandApidra 2-40units 300units(3ml) Reusable Yes
owen mumford Autopen3ml Alltypesof3mlcartridges 1-21units 300units(3ml) Reusable Yes exceptNovoNordisk3ml Autopen3ml Alltypesof3mlcartridges 2-42units 300units(3ml) Reusable Yes exceptNovoNordisk3ml
guide to insulin penspen needles
syringes
ThefollowingtablehighlightspenneedlescurrentlyavailableintheUK.Therearefivedifferentneedlelengthsavailable-5mm,6mm,8mm,12mm,and12.7mm-andfourdifferentalternativegaugesorwidths-28G,29G,30G,and31G.AllneedlesshouldfitallInsulinpens(excepttheOptiPenProinsulinpenfromAventis,whichcanonlyusethePenfineneedlefromDisetronic).
Therecommendationisthatanewneedleisusedforeachinjection.
Useafreshsyringeforeachinjection.
Product Name Manufacturer Length Width
BD Microfine + BectonDickinson 12.7mm 29G 8mm 31G 5mm 31G
Novofine NovoNordisk 12mm 28G 8mm 30G 6mm 31G
Unifine Pentips OwenMumford 6mm 30G 8mm 30G 12mm 29G Penfine Disetronic 6mm 31G 8mm 31G 12mm 29G
Name Manufacturer Syringe NeedleLength Capacity Available
BD Microfine + BectonDickinson 0.3ml 8mm 0.5ml 8mm/12.7mm 1.0ml 8mm/12.7mm
Choiceofneedlemanufacturerwilldependprimarilyonpatientchoice.ChoiceofneedlelengthwillbedeterminedbybothpatientchoiceandBMI,butmostpatientswillonlyrequire5mm-8mmneedles.Althoughthereisnoevidenceofneedlelengthrelatingtopain,thereispsychologicalbenefittotheshorterneedles.Thereisariskthat12mm-12.7mmneedlesmayresultininsulinbeinginjectedintramuscularly,especiallyifthepatientisthinanddoesnot“pinchup”subcutaneoustissuebeforeinjecting.
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - potential regimens (type 2 diabetes)
Mostcommonlyusedinsulinregimens Metformincanbecontinuedincombinationwithallinsulinregimes,asoutlinedhere,inpatientswithType2Diabetes:
1. twice daily pre-mixed insulin which includes conventional mixturesofshort-actingandisophaneinsulin,e.g.HumanMixtard.Themostcommonlyusedratiois30/70.Insulinanaloguemixturesareavailablewithapercentageof short-actinginsulinof25%,30%and50%.Short-acting insulin analogue mixtures such as Novomix 30 and HumalogMix25andMix50,arenowavailableandmayhave particular advantages in terms of patient convenience(noneedtowaitbeforeeating)andcontrolof post-meal glucose.
2. once-daily basal insulinincombinationwithoralhypoglycaemicagent,toincludeeitherasulphonylureaoraprandialglucoseregulatorwithMetforminiftolerated.Evidencesuggests that conventional isophane insulin when used in this regimeisbestadministeredeitherintheeveningorbeforebed.Basalinsulinanaloguesincludinginsulinglargineanddetemirhavebeensuggestedforuseonceadayincombinationwithoralagentsastheyhaveparticularadvantagesintermsofnocturnalhypoglycaemia.
3. twice-daily isophane insulinusedasbasalinsulintherapy.Thisapproachislikelytobesupersededbytheuseofonce-dailybasalinsulinanaloguesasdatasuggeststheyareaseffectiveintermsofA1cloweringandhaveareducedriskofhypoglycaemia.Otherfactorssuchascostsandchoiceofinsulindevicemaymeanthecontinueduseoftwice-dailyisophaneinsulin(i.e.HumanInsulatardorHumulinI)insomepatients.
4. formal basal bolus regime(i.e.fourinjectionsofinsulinperday).Short-actinginsulinorshort-actinganaloguesbeforeeachofthemainmealsandbasalinsulin(eitheronceortwicedailyisophaneinsulinoroncedailylong-actinginsulinanalogue,i.e.insulinglargineordetemir).OftenusedinpatientswithType1diabetes.RarelythefirstchoiceinpatientswithType2diabetes.
factors influencing choice of regimen• Isthepatient’slifestylevariable?(e.g.dotheyworkshifts,do
anysportoractivity,haveajobwhichrequireslotsoftravellingandirregulareatingpatterns?)
•Hasthepersongotspecialneedsorneedassistancewithadministrationofinsulin?(e.g.problemswithdexterity,problemswitheyesight,cognitivedysfunction?)
• Isweightanissue?• Isthenumberofinjectionsperdayanissue?• Isthispersonatparticularriskofhypoglycaemia,orcould
hypoglycaemiacauseparticularproblems(e.g.anelderlypersonlivingaloneorculturalreasonssuchasfasting?)
•Wouldamovetoinsulintherapyparticularlyaffecttheperson’squalityoflifeoroccupationalchoices(e.g.aretheyataxidriver,orholdaHGVlicence?)
•Arethereanyspecificculturalneedsorculturalreasonswhichwouldaffecttheirperceptionsofinsulintherapy?
Anappropriateinsulinregimeisusuallyrequiredtoaddressbothbasal,i.efastingandpre-prandialglucoselevelsandpost-prandial(post-meal)excursions.Atraditionalisophane(mediumacting)insulingiventwicedailysuchasHumulinIandHumanInsulatardaddressesbasalhyperglycaemia.However,thelong-actinginsulinanaloguessuchasinsulinglargineandinsulindetemirwhicharebecomingmorepopular.Theyhavetheadvantageofgreaterpredictability,potentiallylessweightgain,andlowerriskofhypoglycaemia,particularlyatnight.
Addresspost-mealglucoseexcursionswiththeuseoftheshort-actinginsulins,eitherusedaloneorincombinationasamixedinsulin.Thedisadvantagesarethatsomehavetobeinjected20/30minutesbeforeameal.Patientsneedtosnackbetweenmealsandthereisariskofhypoglycaemia.Short-actinginsulinanaloguessuchasNovorapid(aspart)andHumalog(lispro)andApidra(Glulisine)haveadvantagesintermsofconvenience,canbeinjectedwith,orindeed,aftermeals,arebetteratcontrollingpost-prandialglucosewithlessneedforsnacks,andhavealowerriskofhypoglycaemia.
targets of therapy• Patientsneedtohavetargetsindividualised.
• OptimumHbA1ctargetshouldbeinlinewithNICEandevidencebase.
• PatientswithType2diabetesshouldbe<7%(6.5%inthoseatparticularriskofcardiovasculardisease).
• Aimforapre-breakfastorfastingglucoselevelof<5.5mmol/l.
• Pre-prandiallevelsatothertimesofthedayat<6mmol/l.
• Post-prandial(i.e.2hoursafteramainmeal)<8mmol/l.
• Post-prandialglucosemonitoringmaynotbeappropriatefor all patients.
titrating doses - key principles• BloodglucosetargetsshouldbeagreedbetweentheHCP
and the patient.• Donotadjustthedoseinresponsetoindividualblood
glucosereadings.Trytolookforpatternsandestablishtheoverall picture.
• Usethemonitoringdiarytoestablishifpatternsexistatdifferenttimesoftheday.
• Takeintoaccountanycommentsdiscussedorrecordedinthemonitoringdiary.Aretheyrelatedtothebloodglucosereadings,eg.eatingpatterns,changesinactivity.
• Viewthebloodglucoseresultsinrelationtothetypeofinsulinandtimingofinjections.
• Wherepossible,decisionre:titratingthedosesshouldbemadebythepatientorinpartnershipwiththeHCP.
• Istheproblemdoserelatedordoesitindicatethattheregimenisnotmeetingthatperson’sneeds?
• Generally,increasesaremadein10%increments• Preventionofhypoglycaemiatakesprecedenceand
generallywherenoothercausecanbefounda20%reductionininsulindoseisrequiredwithcarefulmonitoringand follow up.
background information
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - potential regimens (type 2 diabetes)
adVantages • Thisregimeisrelativelyeasytoteachandsimpleforthe
patient to understand.• Ithaspotentialforbetterpost-prandialglucosecontrol.
disadVantages
MaybemoreeffectiveinloweringHbA1cthanbasalinsulinalone but…• Thereislessflexibility(i.e.unabletoadjusttheshortorbasal
componentofinsulinindependently).
• Patientsmaynotachieveoptimalglycaemiccontrol.
• Timedelayofinjectionwithconventionalmixture(needtoinject20-30minutesbeforeameal).
• Theneedforsnacksbetweenmeals(withthenewanaloguemixturethedelayininjectiontimeisnotrequiredandtheneedforsnacksmaybereduced).
• Titrationmaygetcomplicatedanddifficulttoteach.
• Potentialriskofhypoglycaemiaandweightgain.(Early data from the 4T study).
TWICeDAILYPRe-MIxeDINSULIN Either conventional short-acting and isophane insulin, e.g. Mixtard 30/70, Humulin M3 or analogue mixed insulin, e.g. Novomix 30 or Humalog Mix25.Theadventofshort-actinginsulinanaloguemixturesmeansthatthisregimeisnowavailablewithashortactinginsulinanalogue,eitherasNovomix30with30%short-actinginsulinanalogueorHumalogMix25(25%shortactinginsulinanalogue).
Theparticularchoiceofwhichpre-mixedinsulinisusedmaybeinfluencedby:
• choiceofinsulininjectiondevice• perceivedconvenienceforpatients• potentialforweightgainandriskofhypoglycaemia.
SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYBefore breakfast and before evening meal: Use10unitsb.d.Consideralowerstartingdoseinsomecircumstances,eg.frail,elderlyor‘slim’patients. Remembertheywillneedregularreviewfortitrationofdoses.
TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.• Morningdoseofinsulintitratedagainstpre-lunchandpre-
eveningmealbloodglucosetests:suggest2unitincrementsincreasewithatargetglucoseof<6beforelunchandbeforeeveningmeal.
• Eveningdosetitratedagainstpre-bedandpre-breakfasttest.Titratetotrytoachieveabeforebreakfastbloodglucoseof5.5-6.Bewareofbeforebedtestsof<6:aimforabeforebedtestbetween6and8.Watchcarefullyfortheriskofnocturnalhypoglycaemia.
• InpatientswithType2DiabetesandBMI>19,Metformintherapyshouldbecontinuedatthemaximumtolerateddose,aslongasthereisnocontra-indication,e.g.creatinine>130,unstableheartfailure.(ItisimportanttocheckthatthepersonhasnosymptomsofintoleranceofMetformintherapy.)
INDICATIONfORCHANGeOfReGIMeNIfglycaemictargetsarenotreachedaftertitration,changemayberequired.forexample:-• Ifcontrolremainssuboptimal.
• Hypoglycaemia(particularlyinthenight).
• ExcessiveweightgaindespitecontinuedMetformin.
• Patient’spreferenceorlackofflexibilitywiththeregimeforpatientstoundertakelifestyle(e.g.erraticjoborexercise).
• Ifbeforetheeveningmealdosebloodglucoseremainshighbutfurthertitrationcausesmid-morninghypoglycaemia.Thereare several options:
• Continuepremixedinsulinandaddinshortactinginsulinatlunchtimeifhighbloodglucosebeforeeveningmeal.
• Sticktopre-mixtwiceadaybutchangetheproportionsofinsulin(e.g.HumalogMix50).
Thereisnowalimitedchoicefollowingthediscontinuationofsomepre-mixedinsulins.ThosestillavailableareNovomix30,HumalogMix25,HumalogMix50andMixtard30andHumulinM3.
• Movetoabasalbolusregime(seeappropriatesheet).
• Offerthepatientfreemixingofinsulin.However,thedisadvantageofthisisthatitiscomplicatedtoexplainandteachtopatients,accuracyisanissue,andthepatientswouldneedtomoveawayfromapendevicebacktoaneedleandsyringe.
Theapproachtoinsulintherapyiscontinuouslychanging.Recentevidencesuggestingamoreproactiveandcalculateddoseandtitrationmaybemoreappropriateforthoseexperiencedininsulinmanagement.ToadoptthisapproachseetheLeicestershireDiabeteswebsite:www.leicestershirediabetes.org.uk.
an accredited masters level training module on insulin initiation and management is available. see www.leicestershirediabetes.org.uk for details
adVanced approach to insulin initiation
twice daily premixed insulin
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - insulin initiation - University Hospitals of LeicesterNHS Trust
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
these guidelines are designed for use by those trained and competent in insulin initiation
diabetes - potential regimens (type 2 diabetes)
SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYUse10unitsoncedailyusuallygivenatbedtime(9-10pm)orwitheveningmealforIsophane.
Long-actinganaloguesmaybegivenmorningoreveningatatimesuitableforthepatient,butitmustbeconsistentfromdaytoday.
TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.
Regime for basal insulin analogue is :• Fastingplasmaglucoselevel5.5mmol/l-6.0mmol/l,increase
insulinglargineordetemirdose2unitsevery3daysuntilpre-breakfastbloodglucose≤5.5mmol/landthereisnonocturnalhypoglycaemia.
Althoughbasalanaloguesaredesignedtoworkthroughouta24hourperiod,thismayvarybetween16-24hours.Iftheinsulinistakeninthemorningconsiderthatraisedfastingglucoselevelsmaybeduetotheinsulinrunningoutratherthaninadequatedose,andtwicedailyinsulinmayberequired.
Remember:• Usethreeconsecutiveself-monitoredfastingglucoselevel
(beforebreakfast)toadjustdoses.
• Wait3-4daysbetweenadjustments.
• Reducethedoseiffastingglucosefallsbelow4oranunexplainedhypoglycaemicepisodewasexperienced.Theamountofdecreaseneedstobeatleast2-4unitsor10%,whichever is greater.
INDICATIONfORCHANGeOfReGIMeN• Fastingglucoselevelsareattargetbutifpost-prandialglucose
levelsremainhighdespitemaximumtoleratedoralagents,itmaybeappropriatetostoptheseandchangetoaformalbasalbolusregimen.Seerelevantguidance.
• Controlremainssuboptimal.
• Recurrentunresolvedhypoglycaemia.
• Patient’spreferenceorneedforgreaterflexibilitywithregardtolifestyle(eg.exercise,employment).
Considertwicedailypre-mixedinsulinorformalbasalbolusregimen.
ONCeDAILYbASALINSULIN Either long-acting insulin analogue (Glargine (Lantus), Detemir (Levemir)) or isophane insulin (Humulin I, Insulatard)withcontinuedoralhypoglycaemicagents.• Onceadayinsulinanalogues(Glargine(Lantus),Detemir
(Levemir))aredesignedtoworkthroughouta24hourperiodwitha‘peakless’action.
• Pre-breakfast(fasting)bloodsugarsareagoodindicatoroftheireffectiveness,butrememberthatitinsomeindividualstheydonotlastfor24hoursandmayberequiredtwicedaily.(BDdosingmorelikelywithDetemir).30%ofpatientsinthe4Tstudyrequiredaseconddoseofinsulindetemir.
• The‘peakless’insulinsarenoteffectiveinloweringmeal-time(prandial)risesinbloodsugar.Ifthiscannotbeadequatelycontrolledwithlong-actinginsulinandoralhypoglycaemicagents,shortactinginsulinwillneedtobeadded.
• Basalinsulinanaloguesshouldnotbemixedinsyringeswith other insulins.
• Shouldbeinjectedatapproximatelythesametimeeveryday(2hourwindow).
adVantages • The4Tstudyindicatesthatinpatientswithtype2diabetes
andabaselineHbA1c<8.5%aoncedailybasalinsulinregimeniseffectiveandsafewithalowerriskofhypoglycaemiaandweightgain.
• Itissimpleandeasyforearlyfacilitationtoinsulin.• Potentiallylessweightgain.• Potentialforlessriskofhypoglycaemia.• Relativelyeasyregimeforhealthcareprofessionalstosupport.• Usefulforsymptomreliefiftightcontrolisnotamajorissue.
disadVantages
• Patientsmaynotachieveoptimalcontrol.• Theregimemaynotofferoptimumcontrolofpost-meal(post-
prandial)hyperglycaemia.
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
CHOICeOfORALHYPOGLYCAeMICAGeNT Yourchoiceoforalhypoglycaemicagent,particularlytheinsulinsecretagogue,maybeimportantifchoosingthisregimen.AlwayscontinueMetformininthenormalandoverweightpatientsatthecurrentdoseunlesscontra-indicatedornottolerated.AlwayscheckforsymptomsofMetforminintoleranceinpatients.
• Continueprevioussulphonylureaatunchangeddose.Foreaseoftherapyonemaywishtoconsiderachangetoonce-dailyGlimepiridetitrateduptoadoseof4-6mgorGliclazideMRThisisagoodchoiceifeaseofadministrationisanissue.
Theapproachtoinsulintherapyiscontinuouslychanging.Recentevidencesuggestingamoreproactiveandcalculateddoseandtitrationmaybemoreappropriateforthoseexperiencedininsulinmanagement.ToadoptthisapproachseetheLeicestershireDiabeteswebsite:www.leicestershirediabetes.org.uk
an accredited masters level training module on insulin initiation and management is available. see www.leicestershirediabetes.org.uk for details
adVanced approach to insulin initiation
basal insulin with oral hypoglycaemic agents
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
diabetes - potential regimens (type 2 diabetes)
SIMPLeAPPROACHTOINITIATIONOfINSULINTHeRAPYTostart10unitsb.dofisophaneinsulin,i.e.humanInsulatardorHumulinI.Choiceofdevicemayinfluencethepatient’schoice.
TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.
Totitrateup2unitsperdayuntilthepatientison20unitsperdaywhenthe10%ruleisapplied.Adjusttheinsulinupevery3-4daysinrelationtohomemonitoringresults,e.g.Pre-eveningmealresultsrelatetomorninginsulin,pre-breakfastresultsrelatetoeveninginsulin.
INDICATIONfORCHANGeOfReGIMeN• Hypoglycaemia.
• Suboptimalcontrol.
• Fluctuationsinbloodglucoselevelsinrelationtoinsulinaction.
TWICe-DAILYISOPHANeINSULIN InpeoplewithType2DiabetesandbMI≥19• Metformintherapyshouldbecontinuedatthemaximum
tolerabledoseaslongasthereisnocontra-indication,eg.creatinine>130,unstableheartfailure.Itisimportanttocheckthatthepersonhasnosymptomsofintoleranceofmetformintherapy.
Keypoint: With the advent of the basal insulin analogues and the advantagesintermsofweightgain,predictabilityandreducednocturnalhypoglycaemia.Itisnotlikelythatthisregimewillremainapopularchoice.SeePotentialRegimens-basalInsulinwithOralHypoglycaemicAgentsorTwiceDailyPre-mixedInsulin.
adVantages • Relativelyeasy.
• Lessriskofhypoglycaemia.
• Particularlysuitablewhensomebodyhasaproblemwithhighpre-prandialglucoselevels.
disadVantages
• Difficulttoobtainoptimalcontrol.
• Difficulttomanagepost-prandialhyperglycaemia.
• Doesnotparticularlyallowflexibility.
• Newlongactinginsulinanalogueshaveaddedbenefits.
• Theevidencebaseischangingforotherinsulinregimens.
twice daily isophane
Theapproachtoinsulintherapyiscontinuouslychanging.Recentevidencesuggestingamoreproactiveandcalculateddoseandtitrationmaybemoreappropriateforthoseexperiencedininsulinmanagement.ToadoptthisapproachseetheLeicestershireDiabeteswebsite:www.leicestershirediabetes.org.uk
an accredited masters level training module on insulin initiation and management is available. see www.leicestershirediabetes.org.uk for details
adVanced approach to insulin initiation
University Hospitals of LeicesterNHS Trust
these guidelines are designed for use by those trained and competent in insulin initiation
Working in partnership with PCTs across Leicestershire and Rutland
Date of preparation: May 2008. For review: May 2010.
SIMPLeAPPROACHTOTRANSfeRTObASALbOLUSINSULINTHeRAPY• Ifalreadytakingonceortwicedailybasalinsulin-continuethisandsimplyaddquickactinginsulinorquickactinganaloguebefore
eachmainmeal.• Iftakingpremixedinsulin,calculatehowthepresentdoseofpre-mixedinsulinisdividedintoshortandlongacting,andusethisto
influence decision.
TITRATIONOfDOSeS SeeKeyPrinciplesfromPotentialRegimenssheet.Adjustthebasalinsulin(longacting)toachievesatisfactorypre-breakfastbloodglucoselevels,waiting3-4daysbetweenadjustments.
Althoughbasalanaloguesaredesignedtoworkthroughouta24hourperiod,thismayvarybetween16-24hours.Iftheinsulinistakeninthemorningconsiderthatraisedfastingglucoselevelsmaybeduetotheinsulinrunningoutratherthaninadequatedose,andtwicedailyinsulinmayberequired.
Reducethedoseifbloodsugaristoolowduringthenightorpre-breakfastresultis≤5mmol/lonmorethanoneoccasionor<4.5mmol/lononeoccasion.
Adjusttheshortactinginsulintoachievesatisfactorybloodglucoselevels2hoursafterthemealorbeforethenextmeal.
INDICATIONfORCHANGeOfReGIMeN• Difficultyingivingmultipleinjections.• Changetoamoreregimentedlifestyle,wherepatientdoesnot
requiretheflexibility.
diabetes - potential regimens (type 2 diabetes)
bASALbOLUSReGIMe• Atleastfourinjectionsofinsulinperday.
• Shortactingorshortactinginsulinanaloguesbeforeeachofthemainmeals,andbasalinsulin(eitheronceortwicedailyisophaneorlongactinginsulinanalogues,eg.glargineordetemir).
• OftenusedinpeoplewithType1Diabetes.
• RarelyafirstchoiceinpatientswithType2Diabetes.
• Usefulforpatientswhorequireflexibilityonadailybasis,withirregularlifestyles,variedmealtimesorirregulareatingpatterns,shiftworketc.
Anexampleofsomeoneinwhomthismaybeusefulisanactive,motivatedpersonwithanerraticlifestylewhowantstoimproveglycaemiccontrol.
adVantages • Offersoptimumflexibilityintermsofdietandactivity.
• Potentialforthelowriskofhypoglycaemia.
• Potentialforbettermetaboliccontrolifusedoptimally.
• Closelymimicsnormalinsulinphysiology.
• Potentialforthebestcontrolofbasalandpost-prandialhyperglycaemia.
• Potentialforbetterweightmanagementandlifestylechoice.
disadVantages
• Requiresmultipleinsulininjections.
• Morecomplicatedtosupportandteach.
• Requiresmoreregularglucosetesting.
• Generallymorecomplicated.
Theapproachtoinsulintherapyiscontinuouslychanging.Recentevidencesuggestingamoreproactiveandcalculateddoseandtitrationmaybemoreappropriateforthoseexperiencedininsulinmanagement.ToadoptthisapproachseetheLeicestershireDiabeteswebsite:www.leicestershirediabetes.org.uk
adVanced approach to insulin initiation
formal basal bolus regime
basalbolusregimenwithbasalanalogue (Glargine, Detemir)Addtotaldailydoseofpremixedinsulin.Usuallytakeoff20%.
Insomecircumstancesitmaynotbeappropriatetotakeoff20%,e.g.verypoorglycaemiccontrolorsymptomaticofhighbloodsugars.
Give50%asbasalinsulin.
Divideremaindertocovermealswithquickactinginsulindependantontheireatinghabits.
Eg.Mixtard30:50unitsam,50unitspm. Totaldailydose=100units-20%=80units. Give40unitsasbasalinsulinremaindergivenas12-14unitsofquickactinginsulinwitheachmealdependantoneatinghabits.
basalbolusregimenwithtwicedailyintermediateinsulin(Humulin I, Insulatard)Addtotaldailydoseofpremixedinsulin.Usuallytakeoff20%.Insomecircumstancesitmaynotbeappropriatetotakeoff20%,e.g.verypoorglycaemiccontrolorsymptomaticofhighbloodsugars.Give50%asbasalinsulindividedintotwoequaldoses.Divideremaindertocovermealswithquickactinginsulindependantontheireatinghabits.Eg.Mixtard30:50unitsam,50unitspm. Totaldailydose=100units-20%=80units. 50%ofdosedividedintotwoinjectionsofintermediateinsulin. 20unitsamand20unitspm.Remaindergivenasquickactinginsulinwith12-14unitseachmealdependantoneatinghabits.
ORchangeto:
an accredited masters level training module on insulin initiation and management is available.
see www.leicestershirediabetes.org.uk for details
University Hospitals of LeicesterNHS Trust
Date of preparation: May 2008. For review: May 2010.
premixed insulin regimen is
insulin
Blood Test Out of Target
High = increase previous evenings insulin by 2 units or 10%, whichever is greater
low = decrease previous evenings insulin by 2 units or 10%, whichever is greater
BreakfasT
insulin
Blood Test Out of Target
High = increase breakfast insulin by 2 units or 10%, whichever is greater
low = decrease breakfast insulin by 2 units or 10%, whichever is greater
evening meal
Blood Test Out of Target
High = increase evening meal insulin but not if blood tests at breakfast are 4-5
low = decrease evening meal insulin by 2 units or 10%, whichever is greater
BedTime
Blood Test Out of Target
High = increase breakfast insulin by 2 units or 10%, whichever is greater
low = decrease breakfast insulin by 2 units or 10%, whichever is greater
luncH
note: exclude other causes of high or low blood glucose, such as timings of injections, injection sites, lifestyle changes etc. prior to adjusting insulin dose. • Lookfortrendsover3-4days.• Adjustinsulinevery3-4daysuntiltargetsarereachedorhypoglycaemia
becomesaproblem.
• Consider2ambloodglucosereadingifbloodsugarisintargetatbedtimebutlow,highorvariablebeforebreakfast.
• Alterinsulindoseby10%orby2-4units.• Speakwithyourdiabetesspecialistifunsure.
HOw TO adjusT insulin using BlOOd glucOse resulTs fOr a Twice daily premixed insulin
TARGeTbLOODTeSTSbefOReMeALS target ≥5 - ≤6 target >4 - ≤6 target >4 - ≤6 target >6-8
nB. yOu may need a BedTime snack On THis regimen!
points to remember
Intheabsenceof nocturnalhypoglycaemia
Date of preparation: May 2008. For review: May 2010.
Oral HypOglycaemic agenTs are
lOng acTing insulin is
Blood Test Out of Target
High = increase basal insulin by 2 units or 10%, whichever is greater
low = decrease basal insulin by 2 units or 10%, whichever is greater
BreakfasT
Blood Test Out of Target
High = review oral medication
low = review insulin and oral medication
evening meal
Blood Test Out of Target
High = review oral medication
low = review insulin and oral medication
BedTime
Blood Test Out of Target
High = review oral medication
low = review insulin and oral medication
luncH
note: exclude other causes of high or low blood glucose, such as timings of injections, injection sites, lifestyle changes etc. prior to adjusting insulin dose.• Lookfortrendsover3-4days.• Adjustinsulinevery3-4daysuntiltargetsarereachedorhypoglycaemia
becomesaproblem
• Consider2ambloodglucosereadingifbloodsugarisintargetatbedtimebutlow,highorvariablebeforebreakfast.
• Alterinsulindoseby10%orby2-4units.eg.30unitswouldrequireanadjustmentof3units.
• Speakwithyourdiabetesspecialistifunsure.
HOw TO adjusT insulin using BlOOd glucOse resulTs fOr a Basal insulin regimen wiTH Oral HypOglycaemic agenTs (eg. glargine Or deTemir)
TARGeTbLOODTeSTS target >4 - ≤6
points to remember
wHen using lOng acTing analOgues:if mOsT BlOOd TesTs are HigH Over 24 HOurs increase THe dOse By 2 uniTs Or 10%, wHicHever is greaTerif mOsT BlOOd TesTs are lOw Over 24 HOurs decrease THe dOse By 2 uniTs Or 10%, wHicHever is greaTer
Intheabsenceof nocturnalhypoglycaemia
nB: In certain circumstances background insulin may be given at other times of day or twice daily
dependent on individual needs, such as BGM, hypoglycaemia, lifestyle issues or length of insulin
action, but must be consistent from day to day.
insulin
Background insulin aims to keep blood
glucose steady overnight and so
it may be useful to compare the bedtime
glucose result with the pre-breakfast
glucose result when adjusting the dose.
Consider that raised fasting glucose levels
may be due to the insulin running out
rather than inadequate dose,
and twice daily insulin may be required.
Date of preparation: May 2008. For review: May 2010.
meal relaTed insulin is
BackgrOund insulin is
Blood Test Out of Target
High = increase bedtime background insulin (unless hypo overnight)
low = decrease bedtime background insulin
BreakfasT
Blood Test Out of Target
High = increase lunch related insulin
low = decrease lunch related insulin
evening meal
Blood Test Out of Target
High = increase evening meal related insulin
low = decrease evening meal related insulin
BedTime
Blood Test Out of Target
High = increase breakfast related insulin
low = decrease breakfast related insulin
luncH
note: exclude other causes of high or low blood glucose, such as timings of injections, injection sites, lifestyle changes etc. prior to adjusting insulin dose.• Lookfortrendsover3-4days.• Adjustinsulindosethenextdaytoimprovebloodglucosecontrol.• Changeonetypeofinsulinatatime.
• Consider2ambloodglucosereadingif bloodsugarisintargetatbedtimebut low,highorvariablebeforebreakfast
• Alterinsulindoseby10%orby2-4units. eg.30unitswouldrequireanadjustmentof3units.
• Speakwithyourhealthcareprofessionalifunsure.
target >4 - ≤6 target ≥4 - ≤6 target ≥4 - ≤6 target >6-8
points to remember
HOw TO adjusT insulin using BlOOd glucOse resulTs fOr a Basal BOlus regimen
nB: In certain circumstances background insulin may be given at other times of day or twice daily dependent on individual needs, such as BGM, hypoglycaemia, lifestyle issues or length of insulin action, but must be consistent from day to day.
meal relaTed insulin (quick or short acting)BackgrOund insulin
(see nOTe BelOw)
TARGeTbLOODTeSTSbefOReMeALS
Intheabsenceof nocturnalhypoglycaemia
Background insulin aims to keep blood
glucose steady overnight and so
it may be useful to compare the bedtime
glucose result with the pre-breakfast
glucose result when adjusting the dose.
Consider that raised fasting glucose levels
may be due to the insulin running out
rather than inadequate dose,
and twice daily insulin may be required.