6.1.1 Insulins

Click here for insulin formulary choices.

General Advice

  • Refer to NICE Guideline 17 for information on the management of type 1 diabetes, NICE Guideline NG3 for information on diabetes in pregnancy, and NICE Guideline 28 and COMPASS Therapeutic Notes for further information on the management of type 2 diabetes.
  • Type of insulin, device and needle gauge and length should be specified. Care should be taken to write the brand name in full to avoid errors such as, for example, administration of Humalog® in place of Humalog® Mix25 or Humalog® Mix50.
  • Choice of insulin prescribed is guided by the duration of action and regimen choice, and patient choice regarding device types. The table below indicates preferred choices where all things are equal regarding device choice.
  • Several new high strength, fixed combination and biosimilar insulin products are now on the market. Healthcare professionals and patients need to understand the insulin strength of these products and how to use them correctly, to minimise the risk of medication errors such as the wrong insulin strength being prescribed or supplied. Insulin should only be initiated and managed by healthcare professionals with the relevant expertise and training. For further information on minimising the risk of medication error with insulin, see MHRA Drug Safety Update April 2015.
Rapid (analogue)ShortIntermediateLong (analogue)BiphasicBiphasic Isophane*
Immediate with food15 to 30 mins before food (isophane)* Same time every daySame time every dayUp to 15 mins before foodUp to 30 mins before food
Formulary ChoicesApidra®Actrapid®Humulin I® Abasaglar®**Humalog® Mix 25Humulin® M3
Humalog® 100 Humulin S® Insulatard®Lantus®Humalog® Mix 50Insuman® Comb 15
Humalog® 200 Insuman® RapidInsuman® BasalLevemir®Novomix® 30Insuman® Comb 25
Novorapid®Toujeo®Insuman® Comb 50
Tresiba®100
Tresiba®200
*Human NPH (isophane and biphasic isophane) insulin is the preferred first-choice insulin recommended by NICE for type 2 diabetes
**Insulin glargine is available as different branded products, some of which are biosimilars. It is important they are prescribed by brand name to ensure the patient receives the intended product. Abasaglar® is first choice insulin glargine on the formulary (cost-effective choice)

Prescribing Notes

  • For most people with type 2 diabetes, long-acting insulin analogues offer no significant advantage over NPH insulin.
  • Consider, as an alternative to NPH insulin, using insulin detemir or insulin glargine if:
    • the person needs assistance from a carer or healthcare professional to inject insulin, and use of insulin detemir or insulin glargine would reduce the frequency of injections from twice to once daily or
    • the person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes or
    • the person would otherwise need twice-daily NPH insulin injections in combination with oral glucose‑lowering drugs
  • Clinicians should review and, where appropriate, revise prescribing of long-acting insulin analogues in type 2 diabetes mellitus to ensure that it is in line with NICE guidance.

 

Insulin Pump Therapy

  • Continuous subcutaneous insulin infusion (CSII) is an option for people with type 1 diabetes meeting NICE TA151 recommendations (http://www.nice.org.uk/TA151).
  • CSII therapy should be initiated by a trained specialist team.