Diabetes Source: Medicine Issue Date: 12/2010 Document Status: Approved Review Date: 12/03/15 Next Review: 01/04/2018 Document ID: GENM-GL-94 Version No: 5

Avoid insulin drug errors: Reduce harm to patients Intravenous insulin lasts for only a few minutes. - Make sure empty infusions are changed immediately. Never omit regular insulin in people with type 1 diabetes. - Treat any hypoglycaemia first. Self injection. Enabling people to manage their own diabetes where appropriate reduces insulin drug errors. Usual insulin as soon as possible. -If someone is eating and drinking they rarely need to be on an insulin infusion. Low blood sugars. Treat all hypoglycaemia (glucose below 4mmols) promptly in accordance with hospital policy Increase regular insulin doses during illness. Avoid STAT doses of insulin. Never give single doses of IM or IV insulin. When people are ill they may need big increases in their regular insulin doses. Narrow the food-insulin gap – timing of insulin injection with meals is important. = To do it right you need to know how common insulins work.

Treatment – types of insulin Rapid Acting Analogue Novorapid/Aspart Humalog/Lispro Apidra/Glulisine Should be given within 5 minutes of a meal (Inject and eat)

Short Acting/Neutral Insulins Actrapid Humulin S Insuman rapid Taken 20-30 mins pre food. Peaks at 2-4 hours although can stay in system up to 8 hours (i.e renal Impairment). Often used in intravenous sliding scale. Stat doses are not recommended for one off high glucose readings adjust usual doses of insulin.

Medium and long acting insulins Insulatard Humulin I Insuman Basal Taken 30 mins pre food or bed. Peaks between 1-12 hours but can last up to 24 hours in some patients. Patients may need to have a bedtime snack as will peak overnight (if given at bedtime).

Analogue mixtures - contain rapid acting and slow acting insulin Must be shaken thoroughly! Humalog mix 25 Humalog mix 50 Novomix 30 The fast acting component of this insulin acts twice as fast as other fast acting insulins (e.g. Actrapid, Humulin S). It therefore needs to be given immediately before food/with/just after. Starts working in 15 mins and peaks between 1-2 hours. It can last in system for up to 22 hours but in most is gone by 4 hours.

Mixed Insulins – contain fast acting and slow acting insulin Need to shake to mix thoroughly!! Humulin M3 Insuman comb 15/25/50 Taken 20-30 mins before food. Peaks at 1-8 hours may stay in system for up to 24 hours.

Long Acting Analogue Lantus/Glargine Give alongside IVSS and at the same time each day. Levemir/Detemir If this has not occurred you must ensure lantus or levemir is given the day before IV insulin is discontinued (due to the long action of this insulin it takes time to get into the body). It is unusual for a patient to have fast acting with no background or long acting insulin therefore for example if a patient has only Novorapid prescribed and no Lantus this will most often be an omission but could cause hyperglycaemia and potential DKA

Long Acting Analogue Tresiba/Degludec Give alongside IVSS and at the same time each day If this has not occurred you must ensure that Long-acting analogue insulin is given the day before IVSS is discontinued (due to the long action of this insulin it takes time to get into the patients system). It is unusual for a patient to have fast acting with no background or long acting insulin therefore for example if a patient has only Novorapid prescribed and no long acting insulin this will most often be an omission that could cause hyperglycaemia and potential DKA 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42

Insulin and patients not eating Patients not eating for any length of time need to be on an IV variable rate insulin infusion VRII (formerly known as Iv sliding scale) If the patient is on either Levemir, Lantus or Tresiba/Degludec this should be continued due to their slow acting properties Restart usual insulin ASAP If you have ANY queries please contact the Diabetes Team (nurses bleep 1661, answer phone ext 5306, registrar 1549 or 1213)

Hypoglycaemia treatment Treat all blood sugars less than 4 mmols/l even if patient not symptomatic Treat with fast acting sugar first from one of the following options e.g. one glass of Lucozade, one glass of full sugar Ribena,or two teaspoons of sugar honey or jam. NB: companies decreasing sugar content, may take longer to work. Always follow with a good carbohydrate snack e.g. slice of bread / toast, or 2 biscuits or crackers Please see policy on hospital intranet for full guidance

Hypo boxes are available on all wards