Initiating Insulin Therapy in Patients with Type 2 Diabetes Mellitus

Indications for Insulin Therapy

• In primary care:
  • Symptoms of hyperglycaemia despite lifestyle measures and maximal oral hypoglycaemic agents
  • HbA1c persistently above target despite maximal oral hypoglycaemic therapy. Targets do not need to be as stringent in the elderly patient
  • Intolerance to oral hypoglycaemic agents
• Initiate insulin and refer to secondary care:
  • HbA1c persistenly >7.5% and
  • Known cardiovascular disease
  • Presence of microvascular complications
• Painful neuropathy
• Pregnancy

  Please note:

• The decision to initiate insulin should be made on an individual basis taking into account patient's age, comorbidities, patient's weight and social circumstances eg LGV license
• Consider using weight-reducing drugs eg Orlistat or Sibutramine in obese patients as an alternative to insulin
• Obese patients often do not achieve better glycaemic control on insulin and are more likely to gain weight
• Health professionals initiating insulin should have had prior training eg attended an insulin conversion course

Type of Insulin

• A dietetic review should be encouraged prior to starting insulin therapy to minimise weight gain and emphasise consistent carbohydrate intake
• The type of insulin prescribed may be determined by the insulin injecting device most suitable for the patient's dexterity &/or visual needs.
• Start off with a prebedtime injection of either Glargine or Levemir and continue oral hypoglycaemics except the Glitazones. This will reduce insulin doses required and has been shown to result in better glycaemic control and fewer hypoglycaemic events.
• As glycaemic control deteriorates then you may wish to change to a twice daily long-acting insulin or twice daily insulin mixtures (eg Novomix 30 or Humalog Mix 25) with breakfast and evening meal. The advantage of the insulin mixtures is that they can be injected immediately before or after eating whereas NPH insulin should be injected 15-20 minutes before eating. Additionally, insulin mixtures often provide better diabetes control, particularly in patients who are not overweight. Stop sulphonyluea if you are using an insulin mixture
• Overweight patients should continue Metformin therapy following the initiation of insulin therapy as Metformin reduces insulin requirements, minimises weight gain on insulin and may be cardioprotective. Those with gastrointestinal side effects may be able to continue Metformin at a reduced dose or in slow-release form
• The use of glitazones in combination with insulin is currently unlicensed.

Dose of insulin

• The dose is dependent on the BMI of the patient, with overweight patients requiring higher starting doses because they will be more insulin resistant
• A general guide would be 8-12 units BD, dose to be titrated up slowly by 2-4 unit per dose increments depending on blood glucose readings.
• Increase morning insulin by 2-4 units every 3-7 days until target pre-evening meal blood glucose achieved. Increase evening insulin by 2-4 units every 3-7 days until target fasting glucose achieved.
• Please contact the diabetes nurse educator practitioners for further advice and guidance

Monitoring

• Daily blood glucose testing prior to insulin injection while insulin dose is being titrated
• Once blood glucose stable, then pre-injection blood glucose testing twice a week should suffice.
• Increase monitoring during infection

  Initiation of Insulin in T2DM - General Advice and Patient Education

  Driving - patients should inform the DVLA once they're started on insulin

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  Discuss employment restrictions

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  Re-enforce general diabetes advice

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  Named person contact details

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  Injections

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  Injection technique

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  Use of insulin syringe/ pen/ device

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  Storage of insulin

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  Safe disposal of needles

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  Timing of injections

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  Name and type of insulin

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  Action of insulin

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  Site rotation

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  Never stop insulin

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  Adjusting insulin for
  - overall control
  - special circumstances

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  Diet - Advice on weight

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  Testing

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  Blood testing

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  Timing/frequency

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  Recording results

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  Interpreting results

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  Safe disposal of lancets

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  Hypoglycaemia

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  Causes

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  Recognition

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  Avoidance

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  Treatment
  
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