DISPOSAL OF SHARPS

  • Needles should be clipped off using a "BD Safe Clip" device, which is available on prescription. This shears off and secures up to 2000 needles
  • The syringe minus the needle or the remaining part of the pen needle or used lancets can then be placed and collected in a rigid container (eg empty shampoo bottle).
  • Once full, the container or BD Safe Clip should be securely wrapped and disposed of with the household refuse.
  • Care must be taken at all times to prevent needle stick injury.

INSULIN REGIMENS & DOSE ADJUSTMENT

Insulin is generally given as a twice daily or four times daily (basal bolus) regimen. However depending on individual patient circumstances, other regimens may sometimes be used as below:

  • Once daily e.g. in elderly housebound patients
  • Three times daily e.g. for obese insulin resistant type 2 patients on large insulin doses (using biphasic insulin preparation)

Twice Daily Insulin

Insulin is administered as two injections before meals, usually before breakfast and before evening meal. This is most commonly distributed as a one third:two thirds mixture of soluble and isophane insulin or given as a fixed biphasic insulin e.g. Human Mixtard 30 or Humulin M3. Pre-mixed formulations of rapid acting insulin analogues with intermediate acting insulins are available (e.g. Humalog Mix 25) or NovoMix 30) and are also suitable for twice daily administration. A range of other fixed insulin combinations is also available and suitable for a twice daily injection regimen.

To adjust insulin doses on a 'free-mixing' regime

  • If glucose high/low before breakfast, increase/decrease EVENING long acting insulin.
  • If glucose high/low before lunch, increase/decrease MORNING short acting insulin.
  • If glucose high/low before tea, increase/decrease MORNING long acting insulin.
  • If glucose high/low before bed, increase/decrease EVENING short acting insulin.

To adjust insulin doses for a fixed (biphasic) insulin mixture

  • If glucose high/low before breakfast, increase/decrease EVENING insulin dose
  • If glucose high/low before tea, increase/decrease MORNING insulin dose
  • Other adjustments may necessitate a change in components of the mixture. For further advice, contact your local Diabetes Specialist Nurse.

Basal Bolus Regimen

This consists of an injection of a soluble insulin or rapid-acting insulin analogue before each of three main meals (bolus), with a basal insulin supply, usually given in as late in the evening as possible (before bedtime). Suitable basal insulins include Isophane preparations (e.g. Insulatard or Humulin I) or Glargine (LINK).

For regimens using isophane insulins, approximately 30% of the total daily insulin is provided as the basal insulin and the remainder divided and given as bolus doses prior to each meal. See below for regimens including Glargine,(LINK).

A multiple injection regimen does not necessarily translate into better blood glucose control, on average, than a twice-daily regimen. The main advantage is improved flexibility, especially in coordinating insulin doses with meal size and physical exercise. It is therefore most suited to patients with an active lifestyle or those on shift work. It is not suitable for patients in whom insulin omission is suspected or admitted.

For dosage adjustment with basal bolus regimen:

  • If glucose high/low before breakfast, increase/decrease EVENING long acting insulin
  • If glucose high/low before lunch, increase/decrease MORNING short acting insulin
  • If glucose high/low before tea, increase/decrease LUNCHTIME short acting insulin
  • If glucose high/low before bed, increase/decrease TEATIME short acting insulin

 

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PRINCIPLES OF DOSAGE ADJUSTMENT

Here are some general guidelines that should be borne in mind when advising on a change in insulin dose

  • Never change insulin on the basis of a one off reading
  • Always check monitoring technique
  • Ask and check about injection technique
  • Identify the periods of day in which the greatest problems are occurring and look for a pattern in readings

Are monitoring results credible?

  • Is monitoring technique accurate? Low readings can sometimes be caused by using insufficient blood on the monitoring strip
  • Review insulin dose
  • Review injection sites
  • Review lifestyle factors e.g. eating patterns, exercise, working patterns & alcohol consumption
  • Review whether poor control in one period of the day is not a hangover from a previous period
  • Agree an adjustment of dose by 2 units initially
  • Most patients are capable at becoming skilled at self-adjustment of their regime.

Over Insulinisation

The following symptoms are suggestive of over insulinisation:

  • Recurrent Hypos
  • Wildly swinging glucose values
  • Weight gain
  • Subtle features of chronic hypo
    • headache
    • need to eat
    • personality change in elderly

Too Little Insulin

The following symptoms are suggestive of too little insulin:

  • Chronic hyperglycaemia/osmotic symptoms
  • Weight loss
  • Generally unwell
  • Nocturnal osmotic symptoms (thirst, nocturia)

Continuous Insulin Pump Therapy (CSII)

Continuous insulin pump therapy provides an alternative way of delivering insulin. The pump is worn 24 hours per day and delivers short acting insulin. Insulin is delivered via the pump through a small cannula usually sited subcutaneously in the abdomen, and changed every 2-3 days. Before considering this treatment a number of factors need to be considered. These include suitability for treatment, previous insulin treatments and potential problems with this type of treatment and funding of the therapy.

This should be discussed with the specialist diabetes team.