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

2. 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

3. Disclaimer
We have developed this learning programme to support your practice in this topic area. We recommend that you use it in combination with other established reference sources and training provided to support your clinical role. External websites Where we think it will be helpful, we have provided web links to take you directly to a specific part of a website. However, web links can change and if you have difficulty accessing the information, please go to the organisation’s home page. We are not responsible for the content or accuracy of information of any external websites mentioned in this training package.

4. 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

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

6. 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.

7. 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.

8. 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.

9. Insulin profiles

10. 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 minutes
Continues to have an effect on blood sugars for two-six hours
Clear appearance
NovoRapid® (aspart) Apidra® (glulisine) Humalog® (lispro)

11. 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)

12. 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®

13. 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 hours
Clear in colour
Lantus® (glargine 100 units/mL)
Levemir® (detemir)

14. 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)

15. 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 hours

16. 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 hours
Humulin M3®
Insuman Comb 15®
Insuman Com 25®
Insuman Comb 50®
(biphasic isophane/insulin soluble)

17. 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

18. 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.

19. 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.

20. 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®

21. 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

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

23. Background and mealtime insulin
To view an insulin comparison and identification guide, visit:
Please note, this is an external resource and is not produced by nor updated by CPPE.