Corby Clinical Commissioning Group

Kettering General Hospital NHS Trust

Nene Clinical Commissioning Group
Northampton General Hospital NHS Trust
Northamptonshire Healthcare Foundation Trust

Guidance on Insulin Initiation & Adjustment in patients with Type 2 Diabetes

This guideline does NOT apply to people with Type 1 diabetes. Seek help from the Northants Diabetes
MDT for insulin initiation in newly diagnosed patients with Type 1 diabetes
This guidance is to assist in the decision making when either starting or titrating insulin in patients with Type 2 Diabetes.
The options are not the only ones available but are a good starting point. Assistance and support in other regimes can be
gained from Northants Diabetes MDT. Referral to Northants Diabetes MDT dietitian for diet and lifestyle review is
essential when insulin treatment is being considered. This will ensure that insulin is only commenced in patients in whom
there is no scope for dietary modification, will reduce the risk of excessive weight gain on insulin therapy and ensure that
the patient receives essential carbohydrate advice tailored to the proposed insulin regimen.
Target glycaemic levels
HbA1c: The ideal target for HbA1c is 58mmol/mol. This must be individualised depending on circumstances e.g. frail
elderly patients, those with reduced life expectancy (higher target) or planning pregnancy (lower target) and agreed with
the patient. If in doubt about an appropriate target, please discuss with the Northants Diabetes MDT.
Blood glucose: Pre-meal blood glucose of 4-7 mmol/L should achieve an HbA1c of ~ 58mmol/mol.
Insulin Regimen Options
Is flexibility in insulin dosing desired and appropriate?

No No

Is HbA1c 64-75 mmol/mol Is HbA1c greater than Yes

75 mmol/mol
Yes
Yes

Basal Insulin Twice Daily Mixture Basal Bolus

Continue oral hypoglycaemic drugs Stop oral hypoglycaemic drugs Once or twice daily basal Insulin and
(except pioglitazone) (except metformin). Insulin bolus insulin with meals; usually
Commence Isophane insulin once or should normally be taken 20- results in injections four or five times
twice daily as first choice: 30 minutes pre breakfast and a day.
• Insuman Basal – 3ml cartridges plus evening meal Stop oral hypoglycaemic drugs
Clikstar pen OR SoloStar disposable pen (except metformin)
• Insuman comb 25 - 3ml
• Insulatard – 3ml cartridges plus Basal Isophane insulin (first choice)
cartridges plus Clikstar pen
Novopen 4 OR Innolet (‘egg timer’) OR • Insuman basal or Humulin I or
disposable device SoloStar disposable pen Insulatard, or consider analogue
• Humulin I – 3 ml cartridge plus basal in discussion with Diabetes
• Humulin M3 – 3ml cartridges
HumaPen Savio OR Kwikpen disposable MDT
plus Savio pen OR Kwikpen
pen PLUS One of the following:
disposable pen
Consider a long acting insulin analogue Bolus analogue rapid acting
(Lantus or Levemir) once daily ONLY if insulin
patient needs a carer/comm nurse to • Humalog (Lispro) – 3ml cartridges
give insulin and use of analogue would plus HumaPen Savio OR Kwikpen
reduce visits from twice to once daily • NovoRapid – 3ml penfill
• Lantus – 3ml cartridges plus ClikStar cartridges plus Novopen 4 OR
pen OR SoloStar disposable pen Flexpen
Analogue once or twice daily • Apidra – Apidra Penfill cartidges
• Levemir – 3ml cartridges plus Novopen plus Clikstar pen device OR
4 OR Flexpen disposable pen Solostar prefilled disposable pen

Also prescribe:
• Pen needles 4 to 6 mm – GlucoRx or Omnican
• Blood Glucose monitoring strips as per guidance and insulin regime
• Sharps bins as per guidance
• Where carer or community nurse is giving insulin, prescribe either 10 ml vial and BD Safety Glide 0.5ml/50unit insulin syringes OR
pens and BD Auto Shield Duo with retractable needles to reduce the risk of needle stick injury

For further support and advice contact

Northants Diabetes MDT 01327 708113 or 01536 492121 or email diabetes.northants@nhs.net
Ratified: Northamptonshire Prescribing Advisory Group December 2014
 Basal Insulin titration
Insulin: Insuman Basal, Insulatard or Humulin I (first choice)
Levemir or Lantus (ONLY if patient needs a carer/community nurse to give
insulin and use of analogue would reduce visits from twice to once daily)
Start dose: 10 units usually in evening/bedtime
Note - Continue oral hypoglycaemic drugs (except pioglitazone)

Blood Glucose Monitoring

Monitor blood glucose at least once daily varying times
- fasting, pre meal and pre bed.

Blood Glucose (BG) persistently above target

• If BG 8-12mmol/L above target increase insulin by 2 units.
• If BG persistently more than 12 mmol/L above target increase insulin by 4 units
• Increase every 3-5 days to achieve BG target levels (usually 4 – 7 mmol/L).
• Seek advice from the Diabetes MDT before increasing above 40 units.
• If BG is high at certain times of the day but there is hypoglycaemia at other times e.g. over-night
discuss with the diabetes MDT as a change of insulin or of carbohydrate intake will be required
• If the fasting blood glucose remains high but the BG is falling overnight, (i.e. the BG is higher at
bedtime than the following morning) a change of insulin will be required to provide prandial insulin.
Blood Glucose (BG) less than 4mmol/L at any time
• If blood glucose is below 4 mmol/L (more than twice a month) reduce dose by 2-4 units

Review
• Once fasting BG target is achieved continue on this insulin dose for 2-3
months then re-check HbA1c.
• If within target review with every 3-6 months with appropriate team ie
practice nurse , district nurse or GP

For further support and advice contact

Northants Diabetes MDT 01327 708113 or 01536 492121 or email diabetes.northants@nhs.net
Ratified: Northamptonshire Prescribing Advisory Group December 2014
 Twice Daily Mixture Insulin Initiation

Insulin: Insuman Comb 25 or Humulin M3

Start dose: 10 – 12 units with breakfast
8 - 10 units with evening meal
Insulin to be injected 20-30mins before breakfast or evening meal
Note - Stop oral hypoglycaemic drugs (except metformin).

Blood Glucose Monitoring

Monitor blood glucose twice daily before
breakfast and before evening meal.
Do some additional tests at different times e.g.
before lunch and bed to ensure these BG readings
are not becoming too low at these times.

Blood Glucose (BG) persistently above target

• If BG 8-12mmol/L above target increase insulin by 2 units.
• If BG persistently more than 12 mmol/L above target increase insulin by 4 units
• If pre-breakfast BG is persistently above target increase evening insulin every
3-5 days to achieve target levels
• If pre-evening meal BG is persistently above target increase morning insulin
every 3-5 days to achieve target levels
• If both above target adjust one dose.
• If BG is high at certain times of the day but there is hypoglycaemia at other
times discuss with the diabetes MDT as a change of insulin or of carbohydrate
intake will be required
Blood Glucose (BG) less than 4mmol/L at any time
• If blood glucose less than 4mmol/L decrease nearest preceding insulin dose by
2-4 units

Review
• Once fasting BG target is achieved continue on this insulin dose for 2-3
months then re-check HbA1c.
• If within target review every 3 months if carers / community nurses are
giving insulin or 6 monthly if self-managing

For further support and advice contact

Northants Diabetes MDT 01327 708113 or 01536 492121 or email diabetes.northants@nhs.net
Ratified: Northamptonshire Prescribing Advisory Group December 2014
 Basal bolus Insulin titration
Notes
1. It is rarely necessary to commence basal bolus from scratch in Type 2 diabetes – most people will progress
from basal only to the addition of a bolus with one or more meals. It may be necessary to reduce the basal
dose when bolus insulin is introduced – this will depend on how high the BG is.
2. Advice from diabetes MDT dietitian concerning carbohydrate intake is essential

Basal (Isophane) dose: Insuman basal (first choice), Humulin I or Insulatard 6 units bd
or Levemir or Lantus od 10 units
*Bolus: NovoRapid (first choice)
or Humalog or Apidra 4– 6 units with meals
* May vary depending on carbohydrate content of meal and physical activity

Monitor blood glucose up to 4 times a day

Before breakfast, before meals and before bed. Do an additional tests at different times e.g. before
lunch and bed to ensure these BG readings are not becoming too low at these times

Blood Glucose (BG) persistently above target

• If BG 8-12mmol/L above target increase insulin by 2 units.
• If BG persistently more than 12 mmol/L above target increase insulin by 4 units
• Increase basal (usually bedtime) insulin every 3-5 days in order to establish pre-breakfast (fasting) BG
target levels (usually 5 – 7 mmol/L
NOTE: Increasing the basal dose may necessitate reduction of mealtime (bolus) doses as it will raise
general background insulin level
• Pre bed and fasting BG levels should ideally be similar. If BG is very high pre bed, increase the
evening meal bolus to reduce this.
Blood Glucose (BG) less than 4mmol/L at any time
• If blood glucose less than 4mmol/L decrease nearest preceding insulin dose by 2-4 units

Once the correct basal dose is established, titrate mealtime (bolus) doses by 2 units up or down to
achieve BG targets:
• adjust breakfast bolus dose to achieve pre lunch BG target
• adjust lunchtime bolus dose to achieve pre evening meal BG target
• adjust evening meal bolus dose to achieve pre bed BG target
• take into account any variation in the amount of CHO to be eaten and the need to correct for an out
of target BG
• discuss with the diabetes MDT if there is difficulty achieving the target

Review
• Once fasting BG target is achieved continue on this insulin dose for 2-3
months then re-check HbA1c.
• If within target review every 3 months if carers / community nurses are
giving insulin or 6 monthly if self-managing

For further support and advice contact

Northants Diabetes MDT 01327 708113 or 01536 492121 or email diabetes.northants@nhs.net
Ratified: Northamptonshire Prescribing Advisory Group December 2014