NICE guidance - choice of insulin therapy in type 2 diabetes
Last edited 02/2022 and last reviewed 02/2022
- 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
- initiate insulin therapy from a choice of a number of
insulin types and regimens
- which insulin to choose?
- 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
- however note that a once-daily regimen may be an option
when initiating this therapy
- consider twice-daily biphasic human insulin (pre-mix)
regimens in particular where HbA1c is elevated above 9.0%
- 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
- preferably begin with human NPH insulin, taken at bed-time or
twice daily according to need
- insulin therapy may be indicated
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:
insulin regimes in Type 2 diabetes
insulin therapy in type 2 diabetes
pragmatic algorithm for the management of glycaemic (glucose) control in type 2 diabetes
NICE - algorithm for management of glycaemia (glucose) in type 2 diabetes