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Treatment Overview

Insulin Therapy

These recommendations are presented in abbreviated form. Readers should refer to the text of the guideline document for a detailed discussion of each of the following topics.

1. Begin insulin therapy when optimized oral glucose-lowering drugs and lifestyle interventions are unable to maintain blood glucose control at target levels (see Glucose control levels). Maintain support for lifestyle measures after introduction of insulin. Consider every initiation or dose increase of insulin as a trial, monitoring the response.
2. Explain to the person with diabetes from the time of diagnosis that insulin is one of the options available to aid management of their diabetes, and that it may turn out to be the best, and eventually necessary, way of maintaining blood glucose control, especially in the longer term.
3. Provide education, including on continuing lifestyle management (Lifestyle management), and appropriate self-monitoring (see Self-monitoring). Explain that starting doses of insulin are low, for safety reasons, but that eventual dose requirement is expected to be 50-100 units/day. Initiate insulin therapy before poor glucose control develops, generally when DCCT-aligned HbA_1c has deteriorated to >7.5 % (confirmed) on maximal oral agents. Continue metformin. Additionally continue sulfonylureas when starting basal insulin therapy. α-Glucosidase inhibitors may also be continued.
4. Use:
   • a basal insulin once daily such as insulin detemir, insulin glargine, or NPH insulin (risk of hypoglycaemia is higher with the last), or
   • twice daily premix insulin (biphasic insulin) particularly with higher HbA_1c, or
   • multiple daily injections (meal-time and basal insulin) where blood glucose control is sub-optimal on other regimens, or meal-time flexibility is desired.
5. Initiate insulin using a self-titration regimen (dose increases of 2 units every 3 days) or by weekly or more frequent contact with a health-care professional (using a scaled algorithm). Aim for pre-breakfast and pre-main-evening-meal glucose levels of <6.0 mmol/l(<110 mg/dl); where these seem not to be achievable use monitoring at other times to identify the profile of poor glucose control.
6. Continue health-care professional support by telephone until target levels (see Glucose control levels) are achieved.
7. Use pen-injectors (prefilled or re-usable) or syringes/vials according to choice of the person using them.
8. Encourage subcutaneous insulin injection into the abdominal area (most rapid absorption) or thigh (slowest), with the gluteal area (or the arm) as other possible injection sites. Bear in mind that reluctance to use the abdominal region may relate to cultural background.

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