INSULIN
Ceri Jones
Diabetes Nurse Facilitator
2013
Who could benefit from insulin
therapy?


People with Type 1 diabetes are dependent on insulin
People with Type 2 diabetes



who have inadequate blood glucose control on optimised
oral hypoglycaemic agents (NICE, 2003).
with contraindications to oral hypoglycaemic agents.
who have recurrent symptoms of hyperglycaemia or
unexplained weight loss.

who are considering pregnancy.

who are pregnant.

who are post acute MI.

who have acute illness or recurrent infection.

who have foot ulceration and/or infection.
Insulin treatment attempts to mimic the
pattern of normal insulin secretion
Insulin (µU/ml)
Short-lived, rapidly
generated meal-related
insulin peaks
70
60
50
40
Low, steady, basal
insulin profile
30
20
10
0
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
Types of insulin



Animal insulin (Used since 1922)

Short acting

Intermediate acting

Mixture of short and intermediate acting
(biphasic)
Human insulin (Since 1982)

Short acting

Intermediate acting

Mixture of short and intermediate acting
(biphasic)
Analogue insulin (Since 1996)

Rapid acting

Long acting (basal insulin)

Mixture of rapid and intermediate acting (biphasic)
What are analogue insulins?


Analogue
(or modern)
insulins are
formed by
modifying human
insulin
molecules
Like soluble
human insulin,
analogue
insulins are
produced by
recombinant DNA
technology
-chain
Gly
s
-chain
s
Ala
Cys
Phe
Thr
s
s
s
Lys
Pro
s
Insulin
lispro
-chain
Gly
s
-chain
s
Ala
Cys
Phe
s
s
Thr
s
Lys
Asp
Pro
s
Insulin
aspart
Hirsch IB. N Engl J Med 2005;352:174–83
Human insulins
Short-acting

Absorbed quickly and last for several
hours
e.g., Humulin S®, Insuman® Rapid
Intermediateand longacting

Premixed

More slowly absorbed, last for up to
24 hours
e.g., Insulatard®, Humulin® I, Insuman®
Basal
Mixture of short- and long-acting
insulin (biphasic human insulin)
e.g.,Humulin M3, Insuman® Comb
Humulin S and Humulin I are registered trademarks of Eli Lilly and Company
Insuman Rapid, Insuman Basal, and Insuman Comb are registered trademarks of Sanofi-Aventis
Insulatard and Mixtard 30 are registered trademarks of Novo Nordisk
ANALOGUE INSULINS
Rapid-acting

Absorbed very rapidly, last only a few hours

Aim to control postprandial glucose
e.g., NovoRapid®, Humalog®, Apidra®
Long-acting

More slowly absorbed
Designed to provide a low level of insulin throughout
day and night

e.g., Levemir®, Lantus®
Premixed

Mixture of rapid- and intermediate-acting insulin
e.g., NovoMix® 30, Humalog® Mix 25/75
Humalog is a registered trademark of Eli Lilly and Company
Lantus and Apidra are registered trademarks of Sanofi-Aventis
NovoRapid, NovoMix and Levemir are registered trademarks of Novo Nordisk
Insulin Regimens

There are a variety of insulin regimens tailored to
meet the individual needs of people with diabetes.

The goal is to have an insulin release profile most
similar to a physiological state.

The treatment option chosen should reflect:
 Type of diabetes



Person’s lifestyle, age and ability to self-test
blood glucose
Presence of obesity
Choice
Types of insulin regimens




Once-daily/twice-daily intermediateor
long-acting (basal) insulin
Once-/twice-/three-times daily
premixed insulin
Basal–bolus therapy
Mealtime rapid-acting insulin
Insulin with or without oral
agents?





The majority of insulins are licensed with
oral drugs
Metformin should be continued wherever
possible
Sulphonylureas can be used with insulin
In February 2007, pioglitazone was
indicated for use with insulin in the UK
Sitagliptin is the only gliptin at present
that can be used with insulin
NICE http://www.nice.org.uk/nicemedia/pdf/NICE_full_blood_glucose.pdf
Royal College of Nursing.
http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf
Once-daily basal insulin


Exact duration depends on the insulin
Insulin analogues may provide 24-hour cover
Intermediate human insulin preparations may only be
active for ~8 hours and have a more pronounced peak
activity
basal human
basal analogue
insulin
insulin
Insulin action

Insulin injection
Time
Schematic representation
Benefits of a once-daily
basal insulin regimen





Requires only one injection per day
May help overcome resistance to
starting insulin injections
Particularly useful when patient’s blood
glucose is high overnight and in the
morning
Useful for patients who require someone
else (e.g., a district nurse) to administer
their insulin
May be associated with fewer side
effects than other regimens1
1. Holman RR et al. N Engl J Med 2007;357:1716-30
Royal College of Nursing.
http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf
Premixed insulin –
once, twice or three-times daily
Premixed human insulin
Premixed
injection
Insulin action
Premixed
injection
Breakfast Lunch Dinner
Premixed analogue insulin
Contains:
 Basal component
 Short-acting
component
Possible regimens:
 Once daily with largest
daily meal (usually
dinner)
 Twice daily with dinner
and breakfast (figure)
 Three-times daily, with
each meal
Schematic representation of twice-daily injections
Benefits of a premixed insulin
regimen



Targets mealtime glucose
Suited to people with fairly regular
lifestyles, who eat similar amounts at
similar times
each day
Can be initiated as one injection per day to
familiarise patient with injecting*

Second or third injections of same insulin in
same device can be added if necessary to
optimise control1
1. Garber AJ et al. Diabetes Obes Metab 2006;8:58–66
*although most patients are started on twice-daily premixed regimens
Basal–bolus therapy
Rapid-acting human insulin
Long-acting human insulin
Rapid
insulin
Rapid
insulin
Lunch
Dinner
Long
insulin
Insulin action
Rapid
insulin
Rapid-acting analogue insulin
Long-acting analogue insulin
Breakfast
Bedtime
Schematic representation of four injections per day
(one long acting, three rapid acting)
Benefits of a basal–bolus
insulin regimen



This regimen produces an insulin
profile that is closest to natural
insulin production by the body
Offers greater flexibility over type
of food and when it can be eaten
Suited to those who are highly
motivated
Insulin practicalities
Timing
•
•
•
Soluble insulin: 30-45 minutes pre-meal
Short-acting insulin analogues: no
more than 15 minutes pre-meal and can
be given post-meal
Intermediate- or long-acting insulins do
not have to be given in relation to a
meal
Insulin practicalities
Storage
•
•
•
•
•
One month in fridge or at room
temperature once the vial has been
opened
Must never be frozen
Store away from source of heat
If refrigeration not available – Frio bags
available
May be damaged by direct sunlight or
vigorous shaking
Injection Technique
© 2004 BD
Injection Technique
© 2004 BD
Injection Technique
© 2004 BD
Injection Technique
© 2004 BD
Injection Technique
© 2004 BD
Injection Technique
Injection Technique
© 2004 BD
Sharps Disposal

Needles from syringes, pen devices and
lancets are classified as group B
clinical waste.

Sharps bins and safe clips are available
on prescription.

Disposal of sharps bin varies depending
on local policy.