DOCUMENT REFERENCE NO: WE/08/GUI0005/NM

Type: Guideline

Diabetes Insulin initiation and adjustment

Relevant to: Clinicians involved with diabetes
Produced by:
Responsible Executive Director:
Date of Approval:
Date of Implementation:
Due Review Date:
Responsible Reviewing Officer:
This document replaces:

Signed:

Community DSN, Primary Care Support

Director of Commissioning

04.01.2010
Immediate after Approval
04.01.2012
Community DSN, Primary Care Support

Diabetes Insulin initiation and

adjustment Version 1 (May 2008)

Chief Executive:

For Office Use Only

Scheme of Publication
Drive:
Name:
X
Scheme of
Publication

Section no:
5

Sub Folder:
commissioning

NHS West Essex Diabetes Insulin Initiation and adjustment

Version 2 January 2010
Issued February 2010

File: as above

WE/08/GUI0005/NM
Page 1 of 6

POLICY VALIDITY STATEMENT

THIS POLICY IS DUE FOR REVIEW ON

04.01.2012

After this date, this document will become invalid.

Policy users should ensure that they are consulting the
currently valid version of the documentation.

Initial insulin prescription

NHS West Essex Diabetes Insulin Initiation and adjustment
Version 2 January 2010
Issued February 2010

WE/08/GUI0005/NM
Page 2 of 6

Indications:

Type 2 diabetes, where oral therapies are failing to achieve

desired target levels

Usual target levels:

HbA1c 7.0%/53mmol/mol or less

Blood glucose before meals 4 7 mmol/l
Blood glucose after meals 6 8 mmol/l
Individual targets according to circumstances may apply

Select from the following options: Once daily insulin choose one:
Good choice for older patients or
introduction to insulin. May achieve
target where HbA1c <8.5%
Gives constant background level.
Continue OHAs (except glitazones)
Use Lantus/Levemir 1st choice where
hypos are a risk

Insulatard or Humulin I first choice

Rx = novopen 4 + Insulatard penfill cartridge

or Innolet (egg timer) disposable

or Humapen Luxura + penfill cartridges
or Humulin I Kwikpen (disposable)
or
Lantus

Rx = Lantus Solostar prefilled disposable

pen
or
Levemir

Rx = Levemir Flexpen (disposable) or

3 ml penfill Levemir cartridges with

Novopen 4 (or Innolet egg timer)
Good for reasonably active, but fairly
habitual lifestyle
Probably better where HbA1c >8.5%/
68 mmol/mol
Stop OHAs (except Metformin)

b.d. mixture
Novomix 30

Rx = Novomix 30 Flexpen (disposable)

OR
Novomix 30 penfill cartridges with Novopen 4
Humalog Mix 25 Rx = Humapen Luxura + Humalog Mix 25

Cartridges or Mix 25 Kwikpen (disposable)

q.d.s (basal bolus)
Good for active lifestyle where
flexibility is important.
Stop OHAs (except Metformin)

Basal = Insulatard or Humulin I or

Lantus or Levemir
Bolus = Novorapid

Rx = as above Once daily

PLUS: Rx = Novorapid Flexpen

or
Novofill penfill cartridges plus
Novopen 4
Also prescribe for all patients:
Sharps safe/guard

Pen needles 6 mm (8 mm if obese)

Supply of blood glucose monitoring strips

BD Safeclip needle clipper

or
Bolus = Humalog (Lispro)

or
Bolus = Apidra

Rx = Humapen Luxura plus

Humalog cartridges or
Humalog Kwikpen
Rx = Apidra Solostar prefilled
disposable pen

Insulin titration
NHS West Essex Diabetes Insulin Initiation and adjustment
Version 2 January 2010
Issued February 2010

WE/08/GUI0005/NM
Page 3 of 6

B.D. (twice daily) insulin mixtures

Novomix 30/Humalog Mix 25

Start dose:
10 - 12 units with breakfast
8 - 10 units with evening meal

Insulin to be injected with meal or

within 15 minutes of eating

Monitor blood glucose twice daily:

Before breakfast and one other, e.g.: Before lunch/evening meal/bedtime/after
a meal

Pre-breakfast blood glucose > target

Increase evening insulin by 2 units (or
10%) every 3 days

Pre-evening meal blood glucose >

target
Increase morning insulin by 2 units (or
10%)

Adjust one dose at a time

Increase insulin by 2 units (or 10%) every 3 days to
achieve target levels usually: 4 - 7 mmol/l before meals
6 - 8 mmol/l after meals
If all blood glucose readings > 12 mmol/l increase
insulin by 4 units.

If blood glucose < 4.0 mmol/l at

any time, decrease nearest
preceding insulin dose by 2 units
(or 10%)

NB: referral to dietician is advisable

For further support and advice contact

Jackie Watts, Diabetes Specialist Nurse (Primary Care Support)
01279 827238
email: jacqueline.watts@westessexpct.nhs.uk

Insulin titration
NHS West Essex Diabetes Insulin Initiation and adjustment
Version 2 January 2010
Issued February 2010

WE/08/GUI0005/NM
Page 4 of 6

M.D.I/Basal bolus insulin

Basal dose: Start Insulatard or Humulin I or Levemir or Lantus 8 - 12 units at

bedtime/evening meal
*Bolus:

Start Novorapid/Humalog/Apidra 2 - 6 units with meals

(* dose according to carbohydrate of food)

Monitor blood glucose 4 times a day

Before breakfast plus others: before meals, after meals, before bed

Titrate basal (bedtime) insulin first in order to establish pre-breakfast levels

4 - 7 mmol/l by increases of 2 - 4 units (or 10%) every 3 days
NOTE: Increasing the basal dose may necessitate reduction of mealtime
(bolus) doses as it will raise general background insulin level

Once the correct basal dose is established, titrate mealtime (bolus)

doses by 2 units up or down to achieve post meal blood glucose levels of
6 - 8 mmol/l. Advise patient regarding adjusting according to prospective
carbohydrate content of the meal

NB: referral to dietician is advised

For further support and advice contact

Jackie Watts, Diabetes Specialist Nurse (Primary Care Support)
01279 827238
email: jacqueline.watts@westessexpct.nhs.uk

Insulin titration
NHS West Essex Diabetes Insulin Initiation and adjustment
Version 2 January 2010
Issued February 2010

WE/08/GUI0005/NM
Page 5 of 6

Once daily Insulatard, Humulin I, Levemir or Lantus

in combination with Oral Hypoglycaemic Agents (OHA)

Start dose 8 10 units

Usually given in the evening/bedtime

Monitor blood glucose twice daily

Before breakfast plus one other, e.g.: before lunch/evening meal/bedtime/after meal

Increase by 2 units (or 10%) every 3 days to achieve pre-breakfast

target usually 4 7 mmol/l
(if all blood glucose readings > 10 mmol/l increase by 4 units)
N.B: Usual post-meal and pre-bed target 6 8 mmo/l

N.B: If blood glucose < 4 mmol/l reduce dose by 2 units or 10%

NB: referral to dietician is advised

For further support and advice contact

Jackie Watts, Diabetes Specialist Nurse (Primary Care Support)
01279 827238
email: jacqueline.watts@westessexpct.nhs.uk

NHS West Essex Diabetes Insulin Initiation and adjustment

Version 2 January 2010
Issued February 2010

WE/08/GUI0005/NM
Page 6 of 6