e.g. older Oxfordshire HbA1c is 75mmol/mol (9%) manageable

1 Oxfordshire Clinical Commissioning Group insulin initiation and adjustment in Type 2 Diabetes Primary Care Guideline This updated guideline is for use by clinicians who have professional competence in insulin initiation and adjustment attendance at Oxfordshire Primary Care Diabetes Courses on insulin initiation and intensification (page 5). insulin initiation should be considered in line with NICE CG87, for patients with type 2 diabetes, whose individual targets for glycaemic control are not achieved on optimum oral treatments. NICE recommendations are to intensify treatment for patients with an HbA1c concentration greater than 58mmol/mol ( ); consider a range of options to achieve this.

2 Prioritise insulin initiation for those patients at highest risk especially of microvascular complications over time, especially for younger patients with the highest HbA1c concentrations. Individual treatment targets should be agreed but ideally aim for HbA1c of 53mmol/mol (7%), avoiding hypoglycaemia. Patient to receive structured diabetes education (Box B). Consider referral to Enhanced Diabetes Dietetic Service for weight management, via eRS. (tel 01865 264933). Re-evaluate oral therapy. Provide and update patient's self-management plan.

3 1. Initial 3. introduction to Intensification insulin for all 2. Intensification from from regime 1. patients and regime 1 but Basal Plus not or 2 and active ideal long term required and reasonably lifestyle where regime in less active but fairly habitual flexibility is active lifestyle lifestyle OR consider if important and older HbA1c is 75mmol/mol (9%) manageable patients or greater. Regime 1. Regime 2. Regime 3. overleaf overleaf overleaf Basal Plus Background Twice daily Insuman Basal or insulin human mixture Humulin I. Insuman Basal or Humulin M3 or PLUS Insuman R or Humulin I Insuman Comb 25 Humulin S.

4 Regular review and education Patient self-management titration plans and education checklist examples are available. Box A Individual targets for blood Box B Structured education glucose should be agreed. Structured patient education should be provided in line with NICE (TA 60). See page 5 for competencies Local adult education courses, Diabetes2gether and Diabetes4ward, are available. Version 2, November 2015. Approved by Area Prescribing Committee Oxfordshire (APCO) November 2015. Review date November 2017 1. Regime 1. Background human insulin regime Insuman Basal or Humulin I.

5 In combination with oral hypoglycaemic agents (see Box D for use of insulin analogues). Start evening dose after individual assessment (see Box A). Up to 10 units usually given in the evening/at bedtime. Monitor blood glucose daily Self test 3-4 times a week fasting glucose before breakfast AND 2-3 times a week once a day at different times AND 4 point profile every 5-6 weeks Adjust dose: Increase by 2 units (or 10%) every 3 days to achieve pre-breakfast target. If all readings are greater than 10mmol/l increase by 4 units (or up to a maximum of 20%).

6 If pre-evening meal blood glucose remains high OR HbA1c remains high despite good fasting blood glucose Start morning dose Up to 10 units If fail to achieve individual targets or encountering Monitor and titrate: as above to achieve challenges pre-evening meal target Consult competent*. colleagues NB If blood glucose is less than 4 Consider intensification mmol/l on 2 consecutive days to regimes 2 or 3. reduce by 2 units or 10% Contact CDS**. Box C. Hypoglycaemia: It is essential that the person starting insulin and their immediate family know what symptoms to expect, how to reduce the risks of hypos and how to treat them.

7 Hypoglycaemia is defined as blood glucose below 4 mmol/l. Too many hypos can lead to loss of hypo awareness. Examples of patient hypoglycaemia leaflets are available. Sick day rules: Patients require education on sick day rules'. *see page 5 for competencies **Community Diabetes Service, tel: 01869 604089, email: Version 2, November 2015. Approved by Area Prescribing Committee Oxfordshire (APCO) November 2015. Review date November 2017 2. Regime 2. Twice daily human mixture regime Humulin M3 or Insuman Comb 25 (see Box D for use of insulin analogues) insulin to be injected 20 minutes before food.

8 Stop sulfonylureas. Starting dose after individual Intensification from Regime 1. assessment (see Box A): Split total daily units into 2 appropriate Up to 10 units before breakfast doses; pre-breakfast and pre-evening Up to 8 units before evening meal meal*. Monitor blood glucose twice daily: breakfast and one other appropriate time. Adjust one dose at a time to achieve Pre-breakfast target: increase evening insulin by 2 units (or 10%) every 3 days Pre-evening target: increase morning insulin by 2 units (or 10%) every 3 days If all readings are greater than 12 mmol/l increase insulin by 4 units (or up to a maximum of 20%).

9 NB If blood If fail to achieve individual targets or glucose is less encountering challenges than 4 mmol/l Consult competent* colleagues decrease nearest Consider changing pre-mix preceding insulin proportions dose by 2 units or Consider intensification to regime 3. 10% Contact CDS**. Box C. Hypoglycaemia: It is essential that the person starting insulin and their immediate family know what symptoms to expect, how to reduce the risks of hypos and how to treat them. Hypoglycaemia is defined as blood glucose below 4 mmol/l. Too many hypos can lead to loss of hypo awareness.

10 Examples of patient hypoglycaemia leaflets are available. Sick day rules: Patients require education on sick day rules'. *see page 5 for competencies **Community Diabetes Service, tel: 01869 604089, email: Version 2, November 2015. Approved by Area Prescribing Committee Oxfordshire (APCO) November 2015. Review date November 2017 3. Regime 3. Basal Plus; Insuman Basal or Humulin I as background AND Insuman R or Humulin S as pre-meal bolus Stop sulfonylureas. (see Box D for use of insulin analogues). Patient on Regime 1 Patient on Regime 2. requiring intensification requiring intensification Starting bolus dose: 2 6 units Split total daily units*.