CPPE Optimise: Insulins Focus on adjusting dose according to blood glucose levels Background learning

Acknowledgements Authors Sallianne Kavanagh, MPharm, MSc Clinical Pharmacy, MRPharmS, IPresc. Lead pharmacist, Diabetes and Endocrinology, Sheffield Teaching Hospitals NHSFT. Joint Chair - Diabetes and Endocrinology Committee, UKCPA Clinical Reviewer Sarah Alton, MPharm, Sheffield Teaching Hospitals NHSFT Re-purposed by Alison Fryer, learning development pharmacist, CPPE

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Insulin Diabetes is a chronic disease and many people will require insulin therapy to achieve their blood glucose targets. A number of different insulin types and regimens are used to manage diabetes. Insulin is available in different concentrations: 100 units/mL 200 units/mL 300 units/mL

Insulin A number of different devices are also available: Vials Cartridges for use in a reusable pen Pre-filled pens Innolet device Pumps

Insulin profiles Background insulin release For a person without diabetes, the pancreas slowly releases a little insulin throughout the day and night. This background insulin is used to move the sugar (glucose) from the blood stream into the cells, giving them the energy source to function. When a meal or snack is eaten, the pancreas releases extra insulin to move the extra glucose into the cells to be used and stored.

Insulin profiles For people with diabetes, insulin injections are used to replace the person’s own insulin. The choice and combination of insulin used is to try and match the insulin profile of a person without diabetes. There are many different types of insulin available and they each differ in their onset and duration of action.

Insulin profiles Insulin is referred to as a background (basal) or mealtime (prandial) insulin. Some products are available as pre-mixed and these contain both the background and mealtime insulin in one injection. Mealtime insulin will have a quick onset of action and a relatively short duration of action. Background insulin will have a slower onset of action and a longer duration.

Insulin profiles

Rapid acting insulin Usually given with a meal or up to 15 minutes after a meal Starts to work in 15 minutes Peak activity at 60-90 minutes Continues to have an effect on blood sugars for two-six hours Clear appearance NovoRapid® (aspart) Apidra® (glulisine) Humalog® (lispro)

Fast acting insulin Usually given immediately before or with a meal Starts to work in about 30 minutes Peak activity between two-four hours Continues to have an effect on blood sugars for up to eight hours Clear appearance Actrapid® Humulin S® (soluble insulin)

Intermediate acting insulin Background insulin Usually given twice a day (morning and bedtime), but can also be given once a day Starts to work in about two hours Peak activity between four-six hours Continues to have an effect on blood sugars for 8-16 hours Cloudy appearance Needs to be mixed prior to injection Humulin I® Insulatard® Insuman Basal®

Long acting insulin Background insulin Usually given once or twice a day (morning and bedtime) Starts to work in about two hours No peak activity Continues to have an effect on blood sugars for 18-24 hours Clear in colour Lantus® (glargine 100 units/mL) Levemir® (detemir)

Super long acting insulin Background insulin Usually given once a day No peak activity Continues to have an effect on blood sugars for more than 24 hours Clear in colour These are concentrated insulin products so never use an insulin syringe, always use the pen provided with a safe pen needle Tresiba® (degludec 100 units/mL or 200 units/mL) Toujeo® (glargine 300 units/mL)

Analogue pre-mixes NovoMix 30® (biphasic aspart) Humalog Mix25® Humalog Mix50® (biphasic lispro) A mixture of rapid acting and longer acting insulin Pre-mixed in various strengths NovoMix 30® - 30 percent mealtime insulin, 70 percent background insulin Humalog Mix25® - 25 percent mealtime insulin, 75 percent background Usually given immediately before or with a meal Starts to work in about 15 minutes Peak activity between one-two hours Continues to have an effect on blood sugars for 12-18 hours

Human pre-mixes Humulin M3® Insuman Comb 15® Insuman Com 25® A mixture of fast acting and longer acting insulin Pre-mixed in various strengths Humulin M3® - 30 percent mealtime insulin, 70 percent background insulin Insuman Comb 15® - 15 percent mealtime insulin, 85 percent background Usually given immediately before or with a meal Starts to work in about 30 minutes Peak activity between two-four hours Continues to have an effect on blood sugars for 12-18 hours Humulin M3® Insuman Comb 15® Insuman Com 25® Insuman Comb 50® (biphasic isophane/insulin soluble)

Insulin combinations and regimens For people with type 2 diabetes, insulin is used to help keep the blood sugar (glucose) levels within a normal range. For most people, this is a blood glucose level between 6 mmol/litre and 10 mmol/litre when tested on the blood glucose machine. Some people will have a different levels to aim for as agreed with their team. Many people with type 2 diabetes will be taking background insulin, eg, the intermediate acting or long acting insulin products. They will need to take this insulin once or twice a day. Intermediate acting Long acting Insulatard Levemir Humulin I Lantus Insuman Basal Toujeo Degludec

Insulin combinations and regimens For people that do not have good control on background insulin: they may be changed to a pre-mixed insulin to be taken with a meal they may have extra mealtime insulin added to the background insulin.

Pre-mixed insulin If a person needs extra insulin to help control their blood sugars after a meal, they may be changed from a background insulin to a pre-mixed insulin.

Pre-mixed insulin Pre-mixed insulin is given with a meal, usually for breakfast and evening meal. Novomix 30® Humalog Mix25® Humalog Mix50® Humulin M3® Insuman Comb 15® Insuman Comb 25® Insuman Comb 50®

Background and mealtime insulin If a person needs to have a multiple injections a day to control the blood sugar (glucose), the long acting insulin will be given either once or twice a day (morning and/or night time). Intermediate acting Long acting Insulatard Levemir Humulin I Lantus Insuman Basal Toujeo Degludec

Background and mealtime insulin The mealtime insulin will be given with the main meals. Fast acting Rapid acting Actapid NovoRapid Humulin S Humalog

Background and mealtime insulin To view an insulin comparison and identification guide, visit: www.panmerseyapc.nhs.uk/media/1261/insulinidentification_201701_s16_v0100.pdf Please note, this is an external resource and is not produced by nor updated by CPPE.