Diabetes guidance 1766.pdf - East Cheshire NHS Trust

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Insulin therapyThe range of insulin is as follows (alphabetical); the prescribing choices should be governed by NICE criteriaShort-acting insulinHuman soluble insulin:Rapid acting human insulin analogues:Actrapid ,Humulin S, Insuman RapidApidra, Humalog, NovoRapid,Intermediate-acting insulinHuman NPH insulin:Humulin I Insulatard, or Insuman BasalHuman NPH biphasic insulin: Humulin M3, Insuman Comb 15, Insuman Comb 25,Insuman Comb 50Biphasic human analogue insulins: Humalog Mix25, Humalog Mix50, NovoMix 30Long-acting human insulin analogues:Insulin detemir (Levemir) Insulin glargine (Lantus)Type 1Patients should be offered a Basal Bolus regimen of long acting insulin analogue and short acting prandialinsulin analogue as first line as this regimen offers the best prospect for work/lifestyle and glycaemic control.For some patients a twice daily biphasic insulin analogue regimen (Pre-mix) may be fully appropriate.If glycaemic control is adequate with a non-analogue insulin regimen then there is no need to alter therapy.Type 2In patients with Type 2 diabetes the expectation is that NICE CG87 is followed.• If other measures do not keep HbA1c to < 58 mmol/mol Hb (or other agreed target) discuss benefits andrisks of insulin treatment.• Insulin treatment should be initiated with a Structured Education Plan which should include a specificrange of knowledge/skill criteria.• Although NICE CG 87 suggests that insulin treatment should begin with human NPH insulin taken atbed time or twice daily according to need, locally the preferred option is pre-mixed human biphasicNPH insulin.• Consider pre-mixed preparations of insulin analogues (including short acting insulin analogues) ratherthan pre-mixed human insulin preparations if- immediate injection before a meal is preferred, or- hypoglycaemia is a problem, or- blood glucose levels rise markedly after meals.• Alternatively, consider a once-daily long acting insulin analogue (insulin detemir, insulin glargine) if- the person needs help with injecting insulin and a long acting insulin analogue would reduce injectionsfrom twice to once daily, or- the person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes, or- the person would otherwise need twice daily basal insulin plus oral glucose lowering drugs, or- the person cannot use the device to inject NPH insulin• Consider switching to a long acting insulin analogue (insulin detemir, insulin glargine) from an NPHinsulin if the person- does not reach target HbA1c because of hypoglycaemia, or- has significant hypoglycaemia with NPH insulin irrespective of HbA1c level, or- cannot use the delivery device for NPH insulin but could administer a long acting insulin analogue, or- needs help to inject insulin and could reduce the number of injections with a long acting analogue.• Review use of sulphonylurea if hypoglycaemia occurs with insulin plus sulphonylurea. The continuedco-administration administration of metformin may well be appropriate - review.
Insulin therapy - continuedPatients with type 2 <strong>Diabetes</strong> where either a decision to initiate insulin therapy has been made ora change of treatment is indicated.Scenario 1 such as a working middle aged maleThe patient has a relatively set daily routine including meal and work time. HbA1c is greater than69mmol/mol Hb.• Oral agents, especially Metformin and / or pioglitazone, are to be continued unless there is a significantreason to stop them.• Start a biphasic NPH human insulin, such as Humulin M3 or Insuman 25, in a twice a day regimen andadjust doses according to the need.• If there is failure to achieve the target HbA1c after a period of 6 months and/or frequent hypoglycaemicepisodes (especially pre-prandial) and/or post prandial glycaemic excursions are unacceptably high and/orpatient’s eating and/or work patterns become erratic consider a comprehensive Practice Nurse / DSN anddietitian review of lifestyle, exercise, weight and diet before altering the choice of insulin.• If there is no improvement consider a biphasic analogue insulin like Novomix 30 or Humalog Mix25 in atwice a day regimen. If there is repeated failure to achieve HbA1c target or further problems considerfurther DSN review prior to a further change of therapy.• Finally consider a basal bolus regimen.Scenario 2 such as a sight impaired lady in her 70’sThe Patient is on maximum tolerated oral therapy but the HbA1c is above the one set for the individual soinitiation of insulin is indicated. Patient lives alone and/or requires someone to do his/her insulin injection andthere is risk of overnight hypoglycaemic episodes and/or otherwise patient would need a twice a day insulinregimen with either an isophane / NPH insulin or biphasic insulin.• Start once daily analogue basal insulin and adjust dose as needed.• Continue all oral agents unless there is a reason to alter them.• Review the situation with other insulin therapy options if there is failure to achieve the targets or anychange in the individual’s circumstances.Scenario 3 such as a shift worker in their 40’sThe patient has ‘poor’ glycaemic control with HbA1c greater than 69mmol/mol Hb and has erratic meals,meal times and work pattern that is difficult to change or the patient has to inject just before a meal andthe patient’s glycaemic control is ‘very poor’ (HbA1c greater than 86mmol/mol Hb).• Start with a comprehensive review of diet, lifestyle and weight by a Practice Nurse/Dietitian/DSN.• Start a basal bolus regimen with analogue mealtime insulin (like Novorapid or Humalog or Apidra) at eachmeal and a basal insulin (like detemir or glargine) once a day.• A basal bolus regimen with human mealtime short acting insulin (like Humulin S) with each meal and abasal human insulin ( Humulin I, Insulatard or Insuman ) may be considered in exceptional situationswhere there is a strong reason to do so. Usually this group of patients need a basal bolus regimen withanalogue insulin.• Adjust doses as needed.• Oral agents especially Metformin and / or pioglitazones are to be continued unless there is a significantreason to stop them. Ideally, all insulin secretogogues should be stopped with any basal bolus regimenunless there is a compelling reason to leave them on.
Page 1 and 2: Eastern CheshireVale RoyalSouth Che
Page 3 and 4: The Newly Diagnosed Diabetic Patien
Page 5 and 6: Glycaemic ControlHbA1c MeasurementH
Page 7 and 8: Self-Monitoring of Blood Glucose -
Page 9: Glycaemic Control in Type 2 Diabete
Page 13 and 14: HypertensionBP targets are the same
Page 15 and 16: Lipids - continuedHDL Cholesterol a
Page 17 and 18: Screening for Diabetic NephropathyS
Page 19 and 20: Active Foot DiseaseUlcerRefer to Sp

Diabetes guidance 1766.pdf - East Cheshire NHS Trust

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