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NICE guidance - choice of insulin therapy in type 2 diabetes

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  • initiation of insulin therapy in type 2 diabetes:

    • insulin therapy may be indicated
      • when other measures no longer achieve adequate blood glucose control (to HbA1c < 7.5% or other higher level agreed with the individual)
      • when starting insulin therapy, use a structured programme employing active insulin dose titration that encompasses:
        • structured education
        • continuing telephone support
        • frequent self-monitoring
        • dose titration to target
        • dietary understanding
        • management of hypoglycaemia
        • management of acute changes in plasma glucose control
        • support from an appropriately trained and experienced healthcare professional

      • when starting insulin therapy in adults with type 2 diabetes, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies

      • NICE suggest that insulin therapy should be initiated from a choice of a number of insulin types and regimens.
        • preferably begin with human NPH insulin, taken at bed-time or twice daily according to need
          • which insulin to choose?
            • initiate insulin therapy from a choice of a number of insulin types and regimens
              • begin with human NPH insulin injected at bed-time or twice daily according to need
              • consider, as an alternative, using a long-acting insulin analogue (insulin detemir, insulin glargine) if:
                • who do not reach their target HbA1c because of significant hypoglycaemia or
                • who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached or
                • who cannot use the device needed to inject NPH insulin but who could administer their own insulin safely and accurately if a switch to one of the long-acting insulin analogues was made or
                • who need help from a carer or healthcare professional to administer insulin injections and for whom switching to one of the long-acting insulin analogues would reduce the number of daily injections

        • when to consider twice-daily biphasic human insulin rather than once daily insulin
          • consider twice-daily biphasic human insulin (pre-mix) regimens in particular where HbA1c is elevated above 9.0%
            • however note that a once-daily regimen may be an option when initiating this therapy

            • consider pre-mixed preparations of insulin analogues rather than pre-mixed human insulin preparations when:
              • immediate injection before a meal is preferred, or
              • hypoglycaemia is a problem, or
              • blood glucose levels rise markedly after meals

        • monitoring if on a once daily insulin regime
          • monitor a person on a basal insulin regimen (NPH insulin or a long-acting insulin analogue [insulin detemir, insulin glargine]) for the need for short-acting insulin before meals (or a pre-mixed insulin preparation)
        • monitor a person using pre-mixed insulin once or twice daily:
          • monitor a person who is using pre-mixed insulin once or twice daily for the need for a further injection of short-acting insulin before meals or for a change to a regimen of mealtime plus basal insulin, based on NPH insulin or long-acting insulin analogues (insulin detemir, insulin glargine), if blood glucose control remains inadequate

Treatment with combinations of medicines including SGLT-2 inhibitors may be appropriate for some people with type 2 diabetes; see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes, dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating type 2 diabetes.

Reference:

Last reviewed 01/2018

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