Insulin Safety know your insulins! There are many! Humalog® Mix25 Humalog® Mix50 Humulin® I Humulin® M3 Humulin® S Humalog® U-100 Humalog® U-200 Abasaglar ® Hypurin® Bovine Isophane Hypurin® Bovine Lente Hypurin® Bovine Neutral Hypurin® Bovine PZI Hypurin® Porcine 30/70 Hypurin® Porcine Isophane Hypurin® Porcine Neutral Actrapid® Insulatard® Levemir® NovoMix® 30 NovoRapid® Tresiba® U100 insulin Tresiba® U200 insulin Xultophy® Lantus® Apidra® Insuman® Basal Insuman® Comb 15 Insuman® Comb 25 Insuman® Comb 50 Insuman® Rapid Toujeo U300 Including insulins which are more concentrated e.g. Tresiba (Insulin Degledec as U100 but also U200) and Tougeo which is Lantus U300 Biosimilar insulins too. Bovine insulin withdrawn from UK market Dec 2017.

Intermediate Acting insulin Neutral Protamine Hagedorn ( NPH) Insulatard, Humulin I, & Insuman basal Onset 2 hours Peak 4-6 hours Duration 8-14 hours

Useful in which situations? Course of steroid therapy where the day time glucose levels rise. Overnight levels are satisfactory. People that graze throughout the day, small frequent meals. Can be used once a day in the evening if high fasting reading present Bedtime administration can however lead to nocturnal hypoglycaemia

Short Acting Insulin Short acting regular human insulin Actrapid, Humulin S, Insuman Rapid Onset within 30 mins Peak 2-4 hours Duration up to 8 hours

Onset: Within 30 mins Peak: 2-4 hours Duration: Up to 8 hours Insulin Insulin Activity 12 Hours 6 18 24 Onset: Within 30 mins Peak: 2-4 hours Duration: Up to 8 hours Short Acting Soluble Human Insulin – Example: Actrapid, Humulin S, Insuman Rapid

Useful in which situations? Can be used to address post prandial rises in blood glucose. When given 20-30 minutes pre breakfast and evening meal due to the duration of action a lunchtime dose may not be required. Will address high post evening meal and pre bed blood glucose levels but unlikely to cause a drop in glucose levels overnight .

Rapid or Quick-acting Insulin Insulin Analogues: Prandial (mealtime insulin) Novorapid (aspart), Humalog (lispro), Apidra (glulisine) Onset less than 15 mins Peak 50-90 mins Duration 2-5 hours (Faster analogue launched in UK 2017 – Fiasp)

Example: Novorapid, Humalog, Apidra Insulin Activity 6 12 Hours 18 24 Onset: Less than 15 mins Peak: 50-90 mins Duration: 2-5 hours Rapid Acting Analogue Insulin – Example: Novorapid, Humalog, Apidra

Useful in which situations? To cover post meal rise - inject with food Can be administered after food if uncertainties around amount of food will be consumed, eg. elderly, children, prison setting. Duration of rapid acting insulin useful in reducing hypoglycaemia particularly during the night-time.

Biphasic insulins (Pre-Mixed Insulin) Biphasic Human- Humulin M3, Insuman comb 15,25,50 Onset within 30 mins Peak 2-4 hours Duration up to 14 hours Analogue Mix Novomix 30, Humalog mix 25 & 50 Onset Less than 15 mins Peak 50-90 mins

Pre-mixed Human Insulin – Example: Humulin M3, Insuman Comb 15/25/50 Insulin Activity 6 12 Hours 18 24 Pre-mixed Human Insulin – Example: Humulin M3, Insuman Comb 15/25/50 Onset: Within 30 mins Peak: 2-4 hours Duration: Up to 14 hours

Pre-mixed Analogue Insulin - 12 Hours Insulin Activity Hours 0 6 18 24 Pre-mixed Analogue Insulin - Example: NovoMix 30, Humalog Mix 25/Mix 50 Onset: Less than 15 mins Peak: 50-90 mins Duration: Up to 14 hours NICE 2015 suggests considering this regime if HBA1c above 9% ( 75mmol/mol) when commencing insulin

Useful in which situations? To cover post meal rise For people who require prandial cover but only wish to inject twice a day and no more. Appropriate if patient has regular meal pattern/lifestyle In certain circumstances mixed insulin can be given once or 3 x a day (need to take into account the profile and individual eating pattern)

Long Acting Insulin Analogues 1st generation –Glargine (Lantus) Detemir (Levemir) (Biosimilar lantus = Abasaglar ) Duration- 1st generation 16 up to 24 hours 2nd generation – Toujeo (Glargine 300units) Degludec (Tresiba 100 or 200 units) 2nd generation 24 up to 42 hours – greater flexibility re injection timing. Onset for long acting analogues approx. 2 hours without a peak Second generation LA analogues onset 30-90 min so a little faster, toujeo lasting up to 28-30 hours in the body

Long Acting Analogue Insulin – Insulin Activity 6 12 Hours 18 24 Onset: 2 hours Peak: None Duration: 18-24 hours Toujeo lasts longer than 24 hours, degludec can last up to 42 hours Long Acting Analogue Insulin – Example: Glargine, Detemir, Toujeo, Degludec*

Useful in which situations? Where once daily dosing would be beneficial eg. community nurse or carer administration. When weight gain needs to be minimised. In those more at risk of admission (flatter profile reduces risk of hypoglycaemia) Concentrated insulin useful in those requiring large doses.

Recommended reading www.leicestershirediabetes.org – for local insulin and GLP1 professional guidelines. 2nd edition. October 2016 ( currently being updated) Valuable reference resource in respect of prescribing insulin and GLP1s Crasto W, Jarvis J, Davies MJ ( 2016) Handbook of Insulin Therapies. Adis. Setty SG, Crasto W, Jarvis J, Khunti K, Davies MJ (2016) New insulins and newer insulin regimens: a review of their role in improving glycaemic control in patients with diabetes. BMJ 9 Feb.