1. Insulin Refresher slides Date of preparation: June 2017
Review date: June 2018
Prepared by Donna Chorley, Pharmacist

2. Insulin refresher session
Types of insulin
Insulin regimens
Insulin errors
Intravenous insulin
Variable Rate Intravenous Insulin Infusion (VRIII)
Perioperative insulin use

3. INSULIN TYPES

4. Types of insulin Rapid acting analogue Short acting (human)
Intermediate acting (human)
Long acting analogue
Biphasic mixtures (human; analogue)
Porcine and bovine rarely used

5. INSULIN PROFILES

6. Rapid acting analogues
NovoRapid (aspart)
Humalog (lispro)
Apidra (glulisine)
↓ risk of hypoglycaemia
Short acting insulin
Soluble insulin
Actrapid; Humulin S; Insuman Rapid
Slower onset
Longer duration

7. Intermediate – Isophane Long-acting analogues
Insulatard; Humulin I; Insuman Basal
Provides background (basal) insulin (Type 2 patients)
Long-acting analogues
Levemir (detemir)
Lantus (glargine)
Tresiba (degludec) (42 hrs)
Basal insulin (Type 1 & some Type 2)

8. Biphasic Human
Humulin M3
Insuman Comb 15
Insuman Comb 25
Insuman Comb 50
Biphasic analogues
NovoMix 30
Humalog Mix25
Humalog Mix50

9. Insulin regimens

10. Insulin Regimens There is no single regimen that will suit all people
Lifestyle and eating habits need to be taken into consideration when deciding which regimen to use
Aim is to provide sufficient background (BASAL) insulin with BOLUS insulin to cover meals

11. Normal insulin secretion
Short-lived, rapidly
generated meal-related
insulin peaks 70 60 50 40
Insulin (µU/ml)
Low, steady, basal
insulin profile 30 20
In healthy adults, normal insulin secretion has two key elements: short-lived, rapidly generated peaks in response to food intake, complemented by a low level of basal insulin to control glucose between meals.
References
Polonsky KS, Given BD, Van Cauter E. Twenty-four-hour profiles and pulsatile patterns of insulin secretion in normal and obese subjects. J Clin Invest 1988;81:442–8 10
6:00
10:00
14:00
18:00
22:00
2:00
6:00
Time of day
Polonsky KS et al. J Clin Invest 1988;81:442–8

12. Insulin regimens
As a guideline – the more active the lifestyle the more fast acting insulin would be used. If the patient is still producing their own insulin but in insufficient quantities ie type 2 a single injection may be sufficient – usually in combination with an OHA.
The most common regimen is bd mix, the most common being 30% soluble insulin. It is not certain that more frequent injections give better control but it does give a greater flexibility of lifestyle

13. Basal Bolus regimen Allows greater flexibility
Uses rapid acting insulin just before each meal
Long acting insulin
(Analogues can be given at any time but must be given same time every day)
Patients can adjust their dose according to CBG level, exercise and quantity of CHO to be eaten

14. Twice Daily regimen Most common regimen used in UK
Biphasic insulin
Suitable for those with regular meal times and diet
Shorter acting component
Controls rise in glycaemic level after breakfast and evening meal
Longer acting component
Maintains glycaemic control from lunch until the early part of the evening and from late evening until the next morning
Snacks may be needed between meals and before bed to prevent hypoglycaemia

15. Once Daily Insulin Type 2 only
Use of intermediate or long acting insulin
Insulatard, Humulin I
Lantus or Levemir (NICE criteria)
Needs to be given same time daily
Can be used in combination with oral antidiabetic medicines (SFU, gliptins)
Adjusted depending on pre breakfast blood glucose level

16. INSULIN ERRORS

17. Potential errors Omission Insulin name / insulin type
Administration time
Insulin dose
Transfer of information
Transcription
Discharge (to GP, to community nurse)
Use of “u” or “iu” instead of units
Wrong syringe

18. Avoiding omission Know who is on insulin
Always prescribe on main prescription chart as:
“Insulin – see diabetic chart”
Endorse supplementary chart section
Plan ahead:
Ensure breakfast dose for next day prescribed
If patient stable prescribe weekend doses in advance
Ensure sufficient insulin in pen/vial for next 2 doses
If insulin due after a hypo
Treat hypo
Give insulin after dose review (with meal)

19. Insulin Names Use brand names Always write name in full Humalog Mix 25
Humulin I
NovoMix 30
Common errors
Humalog instead of Humalog Mix 25
Humulin instead of Humulin I or Humulin M3
NovoRapid instead of NovoMix 30
Lantus / Levemir confused

21. Doses Variable Type 1 patients generally lower doses
Type 2 patients generally higher doses
Idea from King’s College Hospital
Rapid / short acting or biphasic insulin
Confirm all doses over 25 units
Intermediate / long-acting insulins
Confirm all doses over 50 units
If patients carbohydrate counting
Prescribe meal insulin as dose range e.g. 2 to 6 units
Record number of units taken

22. Units Never abbreviate units The use of “u” and “i.u” can be misread
- 10 fold increase in dose given
SGUH chart pre-printed “units”
Remember to write units in full for stat doses and for dose records
Leave a space between dose and units
22 units not 22units

24. Administration times Rapid acting / (short acting)
Always for meals
Intermediate – isophane
Once or twice daily
Usually bedtime if once daily
May be given in morning
Long-acting analogues
Anytime but must be same time everyday
Biphasic mixtures

26. Insulin Syringe
Insulin syringes must be used to measure and administer insulin doses unless a pen device is used
Non-insulin syringes never used
If staff administering insulin must use safety insulin syringes

27. Insulin Pens and Cartridges
One pen – one patient
Store in patient’s POD locker
Stable at room temperature for 4 weeks
Discard all insulin 4 weeks after opening
Do not withdraw insulin from a pen or cartridge with a syringe
If staff administering insulin must use safety needles
(Patients who self-administer should
use standard insulin pen needles)

28. Insulin Strength All formulary insulins at SGUH 100 units in 1ml
Be aware of higher strength insulins
Tresiba 200 units in 1ml (Flextouch pen)
Humalog 200 units in 1ml (Kwikpen)
Toujeo 300 units in 1ml (Solostar pen)

29. Biosimilar insulins Not currently stocked at SGUH
Abasaglar (insulin glargine 100 units in 1ml)
Toujeo (insulin glargine 300 units in 1ml)
Be aware not directly interchangeable with Lantus insulin
Seek advice if patient admitted without own supply
Dose reduction needed for switch to Lantus

30. Planning for discharge
Is patient new on insulin?
Can they self administer?
Refer to Diabetes Specialist Nurse before discharge – at least 48 hours notice
Is a nurse needed to administer / monitor?
Notify community team ≥ 48 hours before discharge
Ensure insulin name, dose and times due are clear
TTO documentation
Insulin name and device
Dose at discharge and whether changed
Use duration box if necessary
Request sufficient pens for 2 weeks if supply needed

31. INSULIN MONITORING

32. Glucose monitoring Capillary blood glucose (CBG)
Lab sample if CBG “Hi”
How frequently?
Any specific situation?
Target range for inpatients:
5 – 7 mmol/L (pre-meal)
Higher levels preferred for frail, older patients

33. Ketone monitoring Important for patients with type 1 diabetes
Monitor for ketones
During periods of acute illness
eg infection, stress, GI disturbances
When CBG > 14 mmol/litre
During pregnancy
Presence of ketones indicates:
Need for therapy change
Possible impending / established ketoacidosis

34. Adjusting insulin doses
Basal bolus:
Adjust basal insulin to correct fasting glucose
Adjust bolus insulin dose for previous meal e.g. adjust breakfast insulin if pre-lunch BG high/low
Twice daily biphasic:
The breakfast injection affects the lunchtime and evening meal blood glucose
The evening injection affects the bed time level and the fasting level the next day

35. Insulin Titration Adjust after several readings – review the trends
Every action has a consequence – make one adjustment at a time
Eliminate all hypoglycaemic episodes first
If need to reduce insulin dose – 10 to 20% reduction
Start the day with good glucose levels – if CBG high throughout day normalise fasting level first
If need to increase insulin dose - 10% increment
DON’T prescribe prn insulin
Facilitator Notes
What are the current blood glucose targets?
Why is it important ot achieve good glycaemic control?
Does the required glucose monitoring frequency differ with the insulin regime?
Is it safe to prescribe as required /PRN short-acting insulin to treat hyperglycaemia?

36. Insulin titration cont’d
PRIOR to adjusting DON’T forget to check:
Injections Sites – where is the insulin being injected?
What is the patient eating or drinking?
Has any new medication been initiated that could have affected the glucose levels?
Has the right insulin been prescribed?

37. Prescription review Review the type of insulins patient is taking
Why is patient on basal insulin and a biphasic?
Why is the patient taking biphasic insulin and gliclazide?
Are the administration times correct?
Rapid/short and biphasic never given at bedtime

38. Intravenous insulin

39. Intravenous insulin – Indications
NBM (variable rate)
Peri-operative / Peri-procedure (variable rate)
DKA / HHS (fixed rate)
Patients who are vomiting (variable rate)
Patients with hyperglycaemia complicating acute renal, cardiac or liver failure (variable rate)
Treatment of hyperkalaemia (fixed rate)

40. Variable Rate Intravenous Insulin Infusion
VRIII

41. Risks / Benefits Advantages of VRIII Disadvantages of VRIII
Flexibility for independent adjustment of fluid and insulin
Accurate delivery of insulin via syringe driver
Allows tight BG control in the intra-operative starvation period
Disadvantages of VRIII
Risk of adverse events leading to serious incidents
Reactive to BG levels not proactive
Increased staff time for monitoring
Delays and difficulties in transfer back to normal regimen may prolong length of stay

42. Insulin infusion rate Rate determined by: Insulin sensitivity
Type 1 patient on low dose subcutaneous insulin dose is sensitive to insulin and requires lower rate
Type 2 patient on large subcutaneous insulin doses is insulin resistant and requires higher rate
Whether long-acting insulin given in previous 12 hours
If Lantus or Levemir given basal requirements met and can infuse at lower rate with a zero option
If no basal insulin given need continuous infusion

43. Oral anti-diabetic agents but no s/c insulin – initial scale 1 or 2

45. Fluid management with iv insulin
Provide glucose as substrate (fuel) to prevent proteolysis, lipolysis and ketogenesis
Optimise intravascular volume status
Maintain serum electrolytes within normal ranges
Current recommendations
0.45% NaCl + 5% glucose % KCl
0.45% NaCl + 5% glucose + 0.3% KCl

46. Monitoring Capillary Blood Glucose (CBG) Every hour
If out of range increase frequency
Potassium
Ideally every 4 hours (VRIII)
In practice if in range 2 readings in 24 hours acceptable
Sodium
Cannula and infusion devices
Duration
Refer to diabetes team if duration > 24 hours

47. Monitoring blood glucose
Monitor CBG every hour
Aim for CBG range 6 to 10 mmol/L
If hyperglycaemia
CBG >12 mmol/L for 3 readings and not falling by ≥ 3mmol/L per hour
Ensure infusion devices and cannula patent
Prescriber to increase to next scale
If hypoglycaemia (CBG < 4mmol/L)
Reduce rate to 0.5 units/hour
If scale zero stop infusion until hypoglycaemia treated
Treat hypoglycaemia
Adjust scale once CBG > 4mmol/L

48. Successful IV Insulin Infusion
Mmol/l 10 6
Desired Pattern
Desired Pattern
Undesirable Pattern

49. Hypoglycaemia Most common side effect of iv insulin
Prevent by frequent CBG monitoring
Treat for “hypo avoidance”
Adjust insulin dose
100 ml 10% glucose iv prn prescription

50. Stopping iv insulin Patient eating and drinking; not vomiting
Intravenous insulin
Half life 3 to 5 minutes
Duration 20 to 30 minutes
First dose of subcutaneous insulin must be given 60 minutes before stopping iv
If basal insulin (Levemir, Lantus, Tresiba) continued alongside VRIII can stop VRIII at any time

53. Perioperative management

54. Perioperative management
VRIII not required if following criteria met:
HbA1c < 69 mmol/mol
CBG between 5 and 11 mmol/L
Short starvation period (missing one meal)
Consider VRIII if any of following apply:
Poorly controlled diabetes and cannot postpone surgery
Missing > one meal
Type 1 diabetes and no background insulin

55. Prescribing guidance on the initiation of VRIII for elective surgeries
Missing only one meal⌘
Missing Two meals
Type I
Type II No
Missing basal insulin♯
CBG between 5-11 mmol/ml on admission
Surgery in the morning initiate VRIII by 8 AM
Surgery in the afternoon initiate VRIII by 12 noon
Yes No
Yes
Initiation of VRIII is not necessary monitor Blood Glucose hourly before and during Procedure/Surgery and 2 hourly post Surgery
♯ Any long/intermediate acting or biphasic insulin
⌘ When the period of NBM is extended from missing only one meal to missing two meals, then VRIII should be initiated as soon as possible
Recent HbA1c < 69 mmol/mol
Yes

56. Morning Surgery Day before surgery - all insulin as usual
Day of surgery
Long- acting analogue
Continue am dose (if recent hypos ↓ dose by 1/3)
Intermediate acting
Half morning dose
If to have VRIII omit morning dose
Rapid acting
Omit morning dose
Biphasic (mixed)
If T1DM or missing > 1 meal – will need VRIII

57. Afternoon Surgery Day before surgery - all insulin as usual
Day of surgery
Long- acting analogue
Continue am dose (if recent hypos ↓ dose by 1/3)
Intermediate acting
Half morning dose
If to have VRIII give usual morning dose
Rapid acting
Give usual morning dose with breakfast
Omit lunchtime dose
Biphasic (mixed)
Give half morning dose with breakfast

58. VRIII – Start time Morning surgery
If well controlled diabetes initiate VRIII by 08:00 hours
If poorly controlled initiate VRIII earlier
Consider starting overnight
Afternoon surgery
If well controlled diabetes initiate VRIII by 12:00 noon

59. Free e-learning module available: the six steps to insulin safety
For all healthcare professionals who manage patients on insulin
Overall aim of reducing insulin errors in clinical practice
Developed by the Primary Care Diabetes Society, in association with the nursing group TREND-UK
Log in or register for free on the Diabetes on the net website  

60. Any questions?