Insulin types, administration and sick day rules

Question 1

What are the 3 aims of insulin therapy?

Answer 1

• Treat hyperglycaemia without causing hypoglycaemia
• Reduce risk of longterm complications
• Maintain a normal lifestyle

Question 2

Rapid acting analogues

Answer 2

• E.g. Novorapid, Humalog
• Injected 5-15 minutes before eating
• 2-5 hours in the body
• used in combination with longer-acting insulin

Question 3

Short-acting analogues

Answer 3

• e.g. Actrapid, Humulin S
• Injected 15-30 minutes before meal
• 8 hours in the body
• used in combination with a longer acting insulin

Question 4

Longer acting insulin

Answer 4

• e.g. Levemir, lantus
• injected at night
• works up to 24 hours
• keep control in-between meals
• used in combination with shorter acting insulin

Question 5

Analogue mixtures

Answer 5

• e.g. Novomix 30, Humalog mix 25
• Mix of short and long acting analogues
• 5-15 minutes before eating
• last 14-16 hours

Question 6

Mixtures

Answer 6

• e.g. Hummulin M3, Insuman comb 15
• Inject 20-30 minutes before eating
• Last 12 hours- usually given twice a day

Question 7

Discuss insulin vial and syringe a delivery device?

Answer 7

• Now very rarely used, never in newly diagnosed but just in patients who have used this for a long time
• The syringes are graduated in units and not volume- 1ml = 100 units
• Available in 0.3, 0.5 and 1 mL sizes

Question 8

Are all insulins the same strength?

Answer 8

• NO not all insulin is the same strength. However, this is a recent development
• Previously all insulin was 100units/mL but now can be 200 and even 300 iu/ml
  e.g.
  Insulin glarginine (toujeou) is 300 IU/mL
  but insulin glarginine (Lantus) is 100 IU/mL
  This creates risk of error

Question 9

Discuss insulin pumps as a method of insulin delivery?

Answer 9

• Provides a continuous basal insulin infusion from an insulin reservoir
• Patient activates the bolus on meal times
• NICE approved pumps in 2003 for those with repeated and unpredictable hypoglycaemia or can be self funded at a cost of £2000-£3000

Question 10

What are the two measurements of insulin needles?

Answer 10

• The length
• The gauge (Thickness)- the higher the gauge number, the thinner the needle

Question 11

What are the lengths of insulin needles available?

Answer 11

5mm, 6mm, 8mm, 12mm, 12.7 mm

Question 12

What is the most commonly used insulin needle size ( gauge and length) ?

Answer 12

8 mm and 30G (0.3 mm)
- size depends on length and thickness

Question 13

Can insulin needles be reused?

Answer 13

They’re single use and so should disposed of in a sharps bin after use
- If used repeatedly, they can become ‘hooked’ which will be more painful
- can increase liperhypotrophy
- can allow bacteria from the needle to enter the body and cause infection

Question 14

Give examples of both some reusable and disposable pens?

Answer 14

Reusable
- Clickstar
- Humane
- Novopen- Novopen 6 and echoplus can remember doses

Disposable
- Solostar
- inlet
- flexpen
- flextouch
- kwikpen

Question 15

What sites can be used for insulin injections and which are the slowest and fastest?

Answer 15

• Abdomen (Fastest)
• Thighs
• Upper arm
• Buttocks (Slowest)

Question 16

Why is it important to rotate insulin sites?

Answer 16

To avoid lipohypertrophy- the thickening and hardening of tissue (fatty lumps under the surface of the skin) which can lead to erratic insulin absorption

Question 17

Describe good insulin technique?

Answer 17

• Rotation of sites
• Wash hands prior and inject into clean and dry skin- don’t use acohol wipes on the skin as this can cause soreness
• Inject at a 90 degree angle into soft fat- should reach the subcutaneous layer and not the muscle - would be painful
• If slim or using a non-fatty area can use the ‘Pinch-up’ technique
• Leave needle in for 10 seconds to avoid leakage

Question 18

What is the purpose of a basal insulin dose?

Answer 18

The basal dose provides a low level insulin release to maintain body tissues and prevent fat and protein catabolism.
- When fasting, the body steadily releases glucose into the blood to our cells supplied with energy.
Basal insulin is therefore needed to keep blood glucose levels under control, and to allow the cells to take in glucose for energy

Question 19

What are the purpose of bolus doses?

Answer 19

• Given after food intake to prevent the dramatic increase in blood glucose as a result of food intake

Question 20

What are the advantages and disadvantages of an insulin regime with long acting basal and short acting bolus?

Answer 20

• A long acting basal at night and multiple Short acting insulin doses at meal times e.g. Novorapid and lantus
  + Flexible- can adjust to exercise, delays in mealtimes etc
  + suitable for shift workers, those who travel in work
• more injections needed

Question 21

What are the advantages and disadvantages of a ‘Twice daily’ insulin regime?

Answer 21

• Short and intermediate acting insulin given as a premixed insulin e.g. Novomix 30 or Humulin M3
  + Simple, relatively good control
  + less injections needed- especially good for those who need someone else to inject them
• Inflexible- have to be given at a set time
• Timed and constant food intake and lifestyle- cant adjust to exercise, mealtimes, lifestyle

Question 22

When may a ‘Once daily’ regime be used?

Answer 22

• A singular dose of long-acting insulin at night e.g. lantus may be used in type 2 diabetics (never type 1)
• Used in combination with oral hypoglycaemics where these alone are not giving sufficient control

Question 23

What is the ‘sliding scale’ used in hospital?

Answer 23

• insulin administered by IV in cases of medical emergencies, prior to operations, during labour
• Give IV infusion alongside IV fluids- rate of infusion is varied with measured blood glucose levels (increase n glucose = increase in rate of insulin per hour)

Intravenous insulin infusion of a variable rate according to regular capillary blood glucose measurements with the aim of controlling serum glucose levels within a specified range. The VRIII is usually accompanied by an infusion of fluid containing glucose to prevent insulin-induced hypoglycaemia.

Question 24

How are patients started on insulin on diagnosis?

Answer 24

• All patients need different regimes- so doses are started low and then gradually increased based on blood glucose levels
• Usually patients need 0.5 iu/kg/day. Roughly 40% of this should be from long-acting insulin and 60% from short acting.
  e.g. if patient is 60 kg = 0.5 x 60 = 30 IU
  40% = 12 units given as a long-acting e.g. Levemir
• Patients can adjust this based on pre-prandial blood glucose (before meals)

Question 25

What is the ‘Honeymoon phase’ in type 1 diabetes?

Answer 25

This is when newly diagnosed diabetics can still produce some insulin from the beta cells. Before injecting insulin, the remaining beta cells are damaged due to trying to maintain the body once many beta cells have died. Once a patient is diagnosed and is given insulin, these beta cells can rest and may begin to recover slightly. this means insulin dose can be lower- however this is not remission and these cells cant support

Question 26

How are insulin doses adjusted?

Answer 26

• A pre-meal blood glucose result is reflective of the previous insulin dose so would be the one that mat need changing
• Doses are adjusted by 10% alloquots
• if blood glucose is low, don’t omit an insulin dose, increase food intake

Question 27

How should insulin be stored?

Answer 27

• Store in fridge prior to use- storage at room temp for 2-3 months can decrease potency by 5-10%
• Once in use, DON’T refrigerate- will slow absorption and may sting
  – avoid freezing- will decrease activity

Question 28

What are important sick day rules for type 1 and 2 diabetics?

Answer 28

• Don’t stop taking insulin injections or medications
• Monitor blood glucose more regularly- even up to every 2 hours
• Monitor ketone levels e.g. use Ketostix
• Drink plenty of fluids
• Replace meals with carbohydrate-containing meals if necessary