Jill Little Diabetes Specialist Nurse Insulin Regimes Jill Little Diabetes Specialist Nurse

Insulin Initiation Used to optimise glucose control To alleviate symptoms Prevent or delay complications Circumstances when insulin is required. Treatment of Type 1 diabetes. Treatment of Type 2 diabetes where OHA’s have failed to control the blood sugar or the patient is intolerant of the drug. Gestational diabetes Drug induced hyperglycaemia (steroids). Treatment of acute diabetic emergencies- HONK (Hyperosmolar non-ketotic hyperglycaemia, DKA (Diabetic ketoacidosis). Surgery

Storage of insulin Stored in fridge door Stable for 28 days out of the fridge Insulin in use should be stored at room temperature No direct heat No direct sunshine Will freeze in hold of plane

Insulin injection sites

Lipohypertrophy What is lipohypertrophy? This means changes, hardening of the subcutaneous fatty tissue. What causes lipohypertrophy? The re-use of damaged pen needles can lead to skin and tissue injuries. This, together with frequent injections in so-called favourite sites, can lead to lipohypertrophy. What are the consequences of lipohypertrophy? Injections into hardened tissue affect insulin absorption making the insulin dose effectiveness difficult to calculate. This can lead to unexplainable blood glucose fluctuations. How can lipohypertrophy be avoided? Change the injection site after every injection. Use pen needles only 1x.

Pen needles Lothian guidance First line use Omnican B Braun 4mm Nanopass/My Life BD Viva/Insupen Special use BD Autoshield cover/Novofine Autocover Need a portfolio of needles to suit all types of patients Therefore guidance only for prescribers

Rapid Acting Analogues Novorapid, Humalog and Apidra Clear insulin, bolus to cover food. Can be given immediately before or after food. 15 minute onset, peak 1-2 ½ hours , lasts 3-5 hours. Flexible.

Rapid acting insulin Onset 15mins, peak 1-2hrs, lasts 3-5hrs Insulin activity 0 2 4 6 8 10 12 14 16 18 20 22 24 Onset 15mins, peak 1-2hrs, lasts 3-5hrs

Short Acting Insulin Actrapid and Humulin S Soluble, clear insulin. Inject 15-30 minutes before food. Also used in emergency and at time of surgery. Can give iv,im as well as sc. SC acts within 30-60 mins, peak 2-4 hrs, last 8 hours. iv effect lasts only 30 minutes.

Short acting insulin Short acting / soluble insulin Onset 15-30mins, peak 2-4hrs, lasts 8hrs.

Intermediate Acting Insulin Insulatard and Humulin I . Cloudy- needs to be resuspended. SC onset 1-2 hrs, peak 3-12 hrs, last 16 hours. Can be mixed with soluble.

Intermediate-acting Insulin Onset 1-2hrs, peak 3-12hrs, lasts 16hrs.

Long Acting Analogue Insulin Background (basal) insulin. Smoother profile compared with Insulatard and Humulin I. Cannot be mixed with other insulins in same syringe. Clear insulin. Insulin Glargine (Lantus) Longer duration of action, 24 hours. Take several days to reach steady state(3-4 days). Detemir (Levemir) Long acting basal analogue. Given either once or twice daily. Abasaglar ( insulin Glargine ) Biosimilair

Lantus- lasts up to 24hrs.

Traditional Insulin Mix. Humulin M3 Mixture of soluble and insoluble insulin 30%/70%. Cloudy- needs to be resuspended. Inject 15- 30 minutes before food SC, onset 30-45mins, peak 8hrs, duration up to 22hrs

Traditional insulin mix. Onset 30-45mins, peak 8hrs, lasts up to 22hrs.

Analogue Insulin Mix. Premixed combinations of short and intermediate acting analogues Cloudy (needs resuspending) 3 different combinations (25, 30, 50) Onset 10 - 20 minutes Peak 1 - 4 hours Duration of action up to 24 hours action time Premixed combinations of insulin analogues are also available. These contain rapid acting analogues and so provide freedom to inject immediately before or immediately after eating

New to market – basal insulin Longacting basal insulin

New to market High‑strength insulin products such as insulin glargine 300 units/ml (Toujeo) have been developed for people with large daily insulin requirements to reduce the number and volume of injections. In 1 randomised controlled trial (RCT) in 549 people with type 1 diabetes, Toujeo had similar efficacy to insulin glargine 100 units/ml (Lantus) in terms of HbA1c reduction, but the basal insulin dose used was higher with Toujeo than with Lantus. There was no benefit of Toujeo over Lantus in terms of reduced hypoglycaemic events. The safety profile of Toujeo is largely similar to that of Lantus. Toujeo is not bioequivalent to Lantus and they are not interchangeable without dose adjustment.

New to market Fiasp was developed with the aim of achieving faster initial absorption, to improve glycemic control after a meal, in people with type 1 and type 2 diabetes

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Xultophy is the first product to combine a basal insulin and an incretin mimetic to allow administration of both drugs in a single subcutaneous injection Insulin degludec NEW TO MARKET Xultophy is a prefilled pen containing a fixed-ratio combination of insulin degludec and liraglutide, licensed for the treatment of type II diabetes in combination with oral hypoglycaemics. Xultophy is the first product to combine a basal insulin and an incretin mimetic to allow administration of both drugs in a single subcutaneous injection PHARMACOLOGY Insulin degludec is a long-acting basal insulin that is given once daily. It forms a depot of soluble multi-hexamers following subcutaneous injection which slowly releases insulin monomers throughout the day. Liraglutide is a glucagon-like peptide-1 (GLP-1) analogue (incretin mimetic) that improves glycaemic control by lowering fasting and postprandial blood glucose.1 Xultophy contains a fixed-ratio combination of insulin degludec 100 units and liraglutide 1.8mg per ml. Doses are administered by subcutaneous injection once daily and can be adjusted in dose steps of 1 unit of insulin degludec and 0.036mg of liraglutide. The maximum daily dose of Xultophy is 50 dose steps (50 units of insulin degludec and 1.8mg of liraglutide).1

U 500 Insulin Concentrated form of short acting insulin Lilly have U500 insulin but available on name basis only in UK. Five times concentration of U100. Onset, peak and length of action the same as for U100 Actrapid Main benefit - patients on large doses of short acting can reduce doses using U500 insulin Improved absorption of insulin Improved glycaemic control

Application Twice Daily Insulin – BD 8-12 hrs apart Once daily insulin + oral hypoglycaemics - Basal Bolus Regime – CHO counting

Other Options CSII (Pump Therapy) SQ Needleless System