Page 28 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)
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170
VOLUME 9 NUMBER 4 • NOVEMBER 2012
HANDS ON
SA JOURNAL OF DIABETES & VASCULAR DISEASE
increase the dose slowly to reduce the risk of side effects – in the case of
insulin, this would be hypoglycaemia. A rule of thumb is that people will
need 0.5 units of insulin per kg of body weight. So, a person weighing
80
kg could need around 40 units of insulin each day. However, the ‘start
low’ policy means that initially only 50–60% of that dose would be given,
with the aim of titrating the dose up slowly over time. This means that the
patient might start on 20–28 units. In reality, though, people commenc-
ing once-daily long-acting insulin usually start on approximately 10 units.
Most twice-daily regimens start at 6–10 units in each injection.
Tony decided that he would prefer to start on a long-acting insulin
once daily in the morning. A simple approach to his new regimen might
be as follows:
Choose a background long-acting insulin such as insulin glargine or
•
levemir in a disposable pen device
10-
unit starting dose given in the morning as his preference,
•
although it could just as easily be given in the evening
Test fasting blood glucose each morning
•
Aim to get the morning blood glucose reading to 4–6 mmol/l
•
If this dose is inadequate to reach this target, increase the insulin dose
•
by two units at a time, maintaining the same dose for at least three
days before deciding that further dose increases are necessary.
Further management would depend on two to three monthly HbA
1
c
meas-
urements. If these remain high, then home testing should be increased
to see what is happening at other times of the day, e.g. after meals. It is
worth remembering that insulin regimens can, and should, be amended
according to how well the diabetes is controlled and any changes in the
patient’s lifestyle.
INJECTION TECHNIQUE
Teach Tony to inject at a 90° angle to the skin surface, rotating injection
sites to avoid skin damage that might affect the absorption of the insulin.
STORAGE OF INSULIN
Insulin can be kept out of the fridge at stable room temperature for up
Advantages and disadvantages of different insulin regimens
Type of regimen
Advantages
Disadvantages
Once daily
One injection, fewer
hypos
Does not respond to
post-prandial rise in
glucose level
Premixed regimen
Can be given once daily
with main meal, twice
daily – a.m. and p.m.
–
or with each meal
to target post-prandial
glucose
More than one injection
may be needed; combi-
nation of two insulins in
one injection gives less
flexibility
Basal bolus regimen
Flexible, because it is
similar to the body’s
natural insulin response
Multiple injections with
frequent blood glucose
testing
to four weeks. It can be stored in the fridge but must not be frozen. It is
important reported back to the nurse during insulin initiation and a pos-
sible cause identified, such as problems with technique, timing of meals
or injections or unusually high activity levels.
ADVICE ON MEALS
Tony should be advised to eat three regular meals a day, including car-
bohydrate with each meal. Healthy eating guidelines should be followed.
Many people starting on insulin will gain weight so healthy eating princi-
ples should be revisited.
OTHER DRUGS
Metformin is usually continued in most patients with type 2 diabetes
starting on insulin therapy. Other drugs may also be continued. In line
with the NICE guidelines, CVD risk should be addressed with a combina-
tion of aspirin, statins and ACE inhibitors.
ONGOING SUPPORT AND EDUCATION
Tony will need to be able to access ongoing support from his health-
care professional, particularly over the first few weeks of insulin therapy.
Weekly reviews should be organised, although these could take place on
the phone as well as in person. It may be best to avoid starting Tony on
insulin on a Friday because there may be less support available to him
over the weekend.
Tony should be given information about the Diabetes UK website and
encouraged to consider taking out membership. As with all other treat-
ments for diabetes, Tony should be reminded that insulin is not a substi-
tute for ongoing healthy lifestyle interventions such as following a healthy
nutrition and activity programme.
The NICE guidelines recommend that all patients with diabetes are
offered ongoing structured education and support. The DESMOND
programme (or your local variation of this scheme) can be extremely
useful.
NICE updated guidelines for type 2 diabetes (2008) avail-
•
able from
Details of some of the insulin initiation courses can be
•
found from the following sources:
–
Insulin Conversion in Primary Care for People with
Type 2 Diabetes – 10 credits at Level 2 – Primary Care
Training Centre Bradford
Tel: 0870 850 0539
–
Insulin for Life course and Intensive Management of Dia-
betes course available via Warwick Diabetes Care
-
ject_index/diabetes/imt2d/
MORE INFORMATION
