1. Insulin initiation in Type 2 Diabetes
NICE
and APC guidance

2. 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

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

4. 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

5. Isophane

6. 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 )

7. 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

8. Not achieving good control Where next?

9. 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

10. 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

11. 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

12. 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

13. Human Biphasic

14. 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

15. 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

16. Analogue Biphasic

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

18. 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

19. 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