Insulin initiation in Type 2 Diabetes NICE and APC guidance

Insulin choice In most case start with human isophane (NPH) at bedtime or twice daily. Occasionally it may be better given once daily in the morning. -Cheapest Insuman Basal -Insulatard Innolet device Alternatives- Insulatard / Humulin I Elderly mealtimes concentrated over short time scale Steroid treatment

Administration considerations Refillable pen- ensure spare pen available Prefilled pen Vial? -District Nurse / Nursing Homes

Isophane Insulins Range Cheapest Insuman basal Solostar Humulin I Kwikpen Insulatard Innolet Insuman basal cartridge Humulin I cartridge Insulatard cartridge Insulatard vial Insuman basal vial (5ml) Humulin I vial Insuman basal Solostar Insuman basal cartridge Insulatard vial

Isophane

Long acting analogues NICE considerations Needs help to inject - D/N or carer Not reaching target HbA1c because of recurrent hypos or has significant hypos regardless of HbA1c Otherwise needs b.d basal and oral medication Unable to use NPH devices ( very few )

Long acting analogues Range: Cheapest Glargine (Lantus Solostar) Detemir (Levemir Flexpen) Detemir (Levemir Innolet) Degludec Flextouch U100 Degludec Flextouch U200 Glargine (Lantus) cartridge Detemir (Levemir) cartridge Degludec cartridges U100 Glargine (Lantus) vial Glargine (Lantus) Solostar Glargine (Lantus) cartridge Glargine (Lantus) vial

Not achieving good control Where next?

Review pattern of blood glucose levels This should inform you of how to proceed with the next step Add mealtime insulin to basal? Likely to escalate to Basal bolus Is this in the best interests of the patient Do they need flexibility over timing and quantity How will weight be affected Switch to biphasic? Simpler regimen Needs regular lifestyle

Two Injections of 30/70 Mix Per Day Insulin in blood 6 7 8 9 10 11 12 1 2 3 4 5 time Breakfast Lunch Evening Meal Sleep

4 Injections Per Day 3 Short + 1 Intermediate Acting (Basal Bolus) Insulin in blood 6 7 8 9 10 11 12 1 2 3 4 5 time There may be a need for injecting isophane bd, rather than od when using quick acting analogues in a basal bolus regimen Breakfast Lunch Evening Meal Sleep

Human biphasic Insulin Range Cheapest Insuman Comb 25 Solostar Humulin M3 Kwikpen Insuman Comb 15 cartridge Insuman Comb 25 cartridge Insuman Comb 50 cartridge Insuman Comb 25 vial Humulin M3 vial Insuman Comb 25 Solostar Insuman Comb 15 cartridge Insuman Comb 25 cartridge Insuman Comb 50 cartridge Insuman Comb 25 vial

Human Biphasic

Biphasic analogue? What is the difference? Mealtime component is either short acting or rapid acting Less overlap between rapid and basal component When would you consider using one? No wait between injecting and eating May reduce risk of hypo especially overnight

Biphasic Analogue Insulins Range Cheapest NovoMix 30 flexpen Humalog Mix 25 Kwikpen Humalog Mix 50 Kwikpen Novomix 30 penfill cartridge Humalog Mix 25 cartridge Humalog Mix 50 cartridge Humalog Mix 25 vial All same price Novomix 30 cartridge Humalog Mix 25 vial

Analogue Biphasic

Short acting Range Cheapest Insuman Rapid cartridges Humulin S cartridges Actrapid vial Humulin S vial Insuman Rapid Actrapid

Rapid-acting analogues Range Cheapest Apidra Solostar Novorapid Flexpen / Flextouch Humalog Kwikpen Apidra cartridges Novorapid cartridges Humalog cartridges Apidra Vial (10ml) Novorapid Vial Humalog Vial Apidra 1p cheaper than Humalog or Novorapid

Best insulin regimen ? One size does not fit all Start with isophane unless there is a good reason not to Escalate treatment according to patient need Try to fit the insulin regimen to the patient rather than get them to fit around the insulin. Work to individual patient target not just QOF target