NICE guidance - choice of insulin therapy in type 2 diabetes

• 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:

• (1) NICE (December 2015). Management of type 2 diabetes.
• (2) NICE (May 2009). Type 2 diabetes: newer agents Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes