1. Start the conversation early
An estimated 4.5 million people in the UK have diabetes, 90% of whom have type 2.1 The United Kingdom Prospective Diabetes Study (UKPDS) suggests that 75% of people with type 2 diabetes will require insulin within five years of diagnosis in order to maintain their HbA1c targets.2 Beta cell function declines with time and optimal glycaemic control becomes more difficult to achieve, necessitating insulin therapy.
Early conversation regarding the progression to insulin therapy can help manage patient expectations and help them mentally prepare. The UKPDS and the Diabetes Control and Complications Trial have conclusively shown that intensive glucose-lowering therapy significantly reduces the risk of diabetes-related complications.2, 3
2. Think about starting insulin
Often insulin initiation is delayed due to a number of factors, including patient reluctance and doctor hesitancy. The SOLVE study showed that the average HbA1c at insulin start was 84mmol/mol (9.8%)4 and the average time from diagnosis to initiation of insulin was nine years.
Think about insulin initiation in the following situations:
- If there is failure to reach glycaemic targets using diet and non-insulin therapies
- When there are worsening symptoms of hyperglycaemia i.e. rapid weight loss, polyuria, nocturia and infections
- Patients with pre-existing diabetes started on corticosteroid therapy may require insulin therapy
3. Consider urinalysis to ensure there is not significant ketosis
Always check for ketones if there is significant hyperglycaemia.
Consistent hyperglycaemia can cause glucose toxicity, increased insulin resistance at the cell level and also reduced ability of pancreatic beta cells to secrete insulin. This in turn can lead to a relative insulin deficiency.
If the patient has significant urinary ketosis, a blood test to rule out ketoacidosis is recommended. This is a venous blood gas, usually best accessed at the local emergency department. Correction of hyperglycaemia can lead to dramatic improvement in insulin secretion. Diabetic ketoacidosis is increasingly being reported in patients with type 2 diabetes and can even be the initial mode of presentation in such individuals. If acidotic, these patients will need insulin, at least initially. Diabetic ketoacidosis is a recognised hallmark of type one diabetes but certain patients with type two diabetes are ketosis-prone and can also develop acidosis.
4. Make sure you have the whole picture when initiating insulin
Prior to initiation of insulin, review the patient’s compliance to their current regimen of oral hypoglycaemic agents.
A dietitian review is strongly recommended to discuss dietary measures again before starting insulin. At the time of starting insulin, patients are often more focused and able to follow dietitian advice.
Having an up to date HbA1c, and ideally evidence of blood glucose monitoring, is very important. It is extremely important that the patient can confidently use the glucometer. Patients need education regarding the importance of monitoring to achieve control but also for safety related to hypoglycaemia. Advise regular monitoring when fasting, before meals and two hours post-meals before initiating insulin, and particularly when starting to facilitate titration of insulin dose.
5. Education is key
The most important part of the plan is patient education. It is important to educate the patient about insulin and the impact of food and physical activity on blood glucose.
Other important points include:
- Insulin injection technique and different needle sizes
- Safe disposal of needles
- Insulin injection site rotation to avoid lipohypertrophy
- Insulin storage – store in the fridge until in use and then can stay out of fridge for one month
Patients must inform the DVLA when on insulin therapy and beware of DVLA monitoring guideline while driving.
6. Consider patient-related factors when choosing the correct insulin and device
There are a variety of insulin devices available, for example:
- Insulin syringes
- Preloaded disposable pens
- Reusable injection pens
It is important to consider the patient-related factors while considering an insulin delivery device.
Patient age, dexterity, cognitive skills, living situation, visual and physical abilities as well as comorbidities need to be factored in. There are a number of devices designed for easier use in certain populations. For example: braille-embossed for visually impaired, devices with memory and time recording function, and devices that allow for poor dexterity, such as in those with severe osteoarthritis and limited thumb extension.
Patient-related factors to consider include their usual daytime activities, meal times, shift work, travel and driving habits, for example if they have an HGV licence. Will weight gain be an issue? Are they at risk of hypoglycaemia? Will the number of daily injections be an issue? Will the patient be reliant on someone to give the injections?
7. An intermediate-acting insulin is normally the best first choice
There are multiple different insulin regimens that could be started for patients with type 2 diabetes.
- Basal insulin (a single injection)
- Pre-mixed insulin (at breakfast and dinner – a combination formulation of rapid- and intermediate-acting insulin)
- Multiple daily injection basal-bolus insulin (consists of long-acting insulin and multiple injections with meals throughout the day to cover meal time spikes)
A single injection at bedtime of an intermediate-acting insulin is often the most feasible and patient friendly way to initiate insulin.
This helps to correct the elevated fasting blood glucose level by supplementing endogenous basal secretion while oral hypoglycaemic medications can be continued. In type 2 diabetes metformin should be continued provided there are no contraindications.
NICE recommends starting with NPH (neutral protamine hagedorn), also known as isophane insulin, such as Humulin I or Human Insulatard.
The starting dose most often used is 10 units, or alternatively a weight-based dose of 0.2 units/kg can be started.
8. Ensure that the patient is educated about hypoglycaemia
One of the biggest fears with insulin therapy is hypoglycaemia. Once again, education regarding symptoms to watch out for is key. Interestingly, one study showed that doctors perceived barriers to insulin treatment differently to patients. Fear of hypoglycaemia, weight gain, injection-related pain and anxiety ranked higher as barriers by doctors than for patients. For severe hypoglycaemia treatment, glucagon 1mg injections (GlucaGon Hypokit) are also available on prescription.
Oral secretologues should be kept under review and adjusted where necessary, for example sulphonlyureas can be reduced or stopped if frequent hypoglycaemia becomes an issue.
9. Close follow up and titration of insulin is essential
Once insulin has been started, the next step is adequate titration until the agreed target has been reached.
One study showed that among type 2 patients who had been initiated on basal insulin, only 7% reached the glycaemic target of an HbA1c of 6.5% after one year of basal insulin therapy.6 Individualised patient targets are important. While achieving glycaemia targets is the goal, this does not have to happen overnight. Starting low and going slow is appropriate.
Fasting blood glucose of between 5-7mmol/L is the aim with once daily basal insulin. The general recommendation is to adjust the insulin dose upwards by 10% increments. Glucose monitoring should be reviewed every 5-7 days and up-titration based on the last 2-3 days. The treat to target trial indicated the success of efforts devoted to titration of insulin dose to target. 7
When once daily basal injection dose is becoming high (a general guide is if the basal dose is reaching >0.5 units/kg daily), then starting prandial regular insulin bolus or rapid acting insulin analogue needs to be consideration.
If there are hypoglycaemic events then dose reduction by 20% is suggested.
The NICE quality standard diabetes in adults includes a statement specifically about insulin therapy and states that ‘trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes.’
10. Consider changing insulin if necessary
Insulin glargine or insulin detemir should be considered an alternative to NPH or isophane insulin if:
- The patient needs assistance to inject insulin
- The patient’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes
- The patient would otherwise need twice daily neutral protamine hagedorn insulin injections in combination with oral antidiabetic drugs
- The patient does not reach their target HbA1c because of hypoglycaemia8
Premixed insulin is another option. These include a rapid-acting insulin analogue and intermediate-acting insulin. These can be used if blood glucose rises markedly after a meal or if the patient prefers to inject before a meal.
Patients on premixed regimens need to be monitored for the need to change to a basal bolus regimen with NPH insulin, for example if blood glucose control remains inadequate.
Refer to the diabetes service when concerned – the community diabetes team and diabetes specialist nurses are integral to optimal management.
Dr Tara McDonnell is a clinical fellow, Ms Jakki Berry is a specialist diabetes nurse and Dr Stephanie E Baldeweg is a consultant physician in diabetes and endocrinology, all at the department of diabetes and endocrinology, University College London Hospital.
- Diabetes Prevalence 2016 (November 2016) – Diabetes UK. https://www.diabetes.org.uk/Professionals/Position-statements-reports/Statistics/Diabetes-prevalence-2016/. Accessed May 16, 2017.
- King P, Peacock I, Donnelly R. The UK prospective diabetes study (UKPDS): clinical and therapeutic implications for type 2 diabetes. Br J Clin Pharmacol. 1999;48(5):643-648. doi:10.1046/j.1365-2125.1999.00092.x.
- Group TDC and CTR. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in insulin-Dependent Diabetes Mellitus. N Engl J Med. 1993;329(14):977-986. doi:10.1056/NEJM199309303291401.
- Khunti K, Damci T, Meneghini et. al. SOLVE Study Group. Study of Once Daily Levemir (SOLVETM): insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice. Diabetes, Obes Metab. 2012;14(7):654-661. doi:10.1111/j.1463-1326.2012.01602.x.
- Nakar S, Yitzhaki G, Rosenberg R, Vinker S. Transition to insulin in Type 2 diabetes: family physicians’ misconception of patients’ fears contributes to existing barriers. J Diabetes Complications. 2007;21(4):220-226. doi:10.1016/j.jdiacomp.2006.02.004.
- Kostev K, Dippel FW, Rathmann W. Glycemic control after initiating basal insulin therapy in patients with type 2 diabetes: a primary care database analysis. Diabetes, Metab Syndr Obes Targets Ther. 2015;8:45. doi:10.2147/DMSO.S76855.
- Riddle MC, Rosenstock J, Gerich J. The Treat-to-Target Trial. Diabetes Care. 2003;26(11). http://care.diabetesjournals.org/content/26/11/3080. Accessed May 17, 2017.
- Diabetes in adults Guidance and guidelines NICE. https://www.nice.org.uk/guidance/qs6. Accessed May 16, 2017.