For guidance on the use of insulin based treatments in type two diabetes see: Type 2 Diabetes Mellitus Treatment Guidance

Insulin pump therapy
See NICE TA151 Diabetes - insulin pump therapy (July 2008)

Obtaining advice
Consultant and DSN Support (for use by health care professionals for urgent advice):

• North Devon District Hospital: Diabetes Specialist Nurses, available from 8am to 5.30pm Monday to Friday on 01271 3222726
• Royal Devon & Exeter Hospital: Duty Consultant Monday to Friday 2pm-2.45pm 07818 002363 or email on rh8.diabetesadvice@nhs.net
• Royal Devon & Exeter Hospital: Diabetes Specialist Nurses, available from 9am to 8pm, seven days a week via the RD&E switchboard (01392 411611)

In the April 2015 edition of Drug Safety Update the MHRA issued advice to health professionals to minimise the risk of medication errors with recently launched high strength, fixed combination and biosimilar insulin products. Before starting treatment with a high strength, fixed combination or biosimilar insulin product:

• consult the summary of product characteristics and any educational material – see below
• ensure that patients read and understand the patient leaflet and any patient education material
• ensure that patients receive appropriate training on the correct use of the product
• give patients a patient booklet and Insulin Passport (or safety card) – where available
• warn patients only to use insulin as they have been trained because using it any other way may result in a dangerous overdose or underdose

Monitor glucose levels closely after starting a new treatment and in the following weeks. You may need to adjust doses and timing of concurrent rapid acting or short acting insulin products and other antidiabetic treatments.

MHRA Drug Safety Update (September 2020): Insulins (all types): risk of cutaneous amyloidosis at injection site

• Injection of insulin (all types) can lead to deposits of amyloid protein under the skin (cutaneous amyloidosis) at the injection site. Cutaneous amyloidosis interferes with insulin absorption, and administration of insulin at an affected site can affect glycaemic control
• Remind patients to rotate injection sites within the same body region to reduce or prevent the risk of cutaneous amyloidosis and other skin reactions (for example, lipodystrophy)
• Consider cutaneous amyloidosis as a differential diagnosis to lipodystrophy when a patient presents with subcutaneous lumps at an insulin injection site (see Drug Safety Update for further information)
• Advice is provided for patients who are currently injecting into a "lumpy" area.

Specialist Pharmacy Service (07 July 2023): Insulins able to support switching from GLP-1 receptor agonists. Further information is provided below under ‘Intermediate and long-acting insulins’.

All insulins should be prescribed by brand to avoid any confusion.

6.1.1.1 Short-acting insulins

Rapid-acting human insulin analogues

Rapid-acting human insulin analogues are shorter acting than ordinary soluble insulin and may be advantageous as they can be injected at the start of a meal (see also Biphasic Insulins below). They may be used in patients whose mealtimes are unpredictable, who eat late in the evening or are prone to early nocturnal hypoglycaemia.

Prescribe by brand. There are three insulin aspart and three insulin lispro entries below. Biosimilar insulin aspart (Trurapi) and biosimilar insulin lispro (Admelog) are first-line, as these are cost saving compared with NovoRapid (insulin aspart) and Humalog (insulin lispro). Fiasp (insulin aspart) and Lyumjev (insulin lispro) have a faster initial rate of absorption and are to be prescribed in primary care on the recommendation of the specialist team.

NICE NG17 and NICE NG28 recommend when starting an insulin for which a biosimilar is available, the product with the lowest acquisition cost should be used. When people are already using an insulin for which a lower cost biosimilar is available, discuss the possibility of switching to the biosimilar. The NHS Devon Medicines Optimisation Team has produced supporting information and prescribing guides for clinicians and patient information leaflets to support the change from NovoRapid to Trurapi and from Humalog to Admelog.

Insulin aspart

Trurapi

(Insulin aspart)

• Vial (10ml) 100units/ml (£11.97 = 10ml)
• Cartridge (3ml) 100units/ml (£19.82 = 5 cartridges)
• Solostar pre-filled disposable injection device (3ml) 100units/ml (£21.42 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required. In addition, Trurapi is an insulin aspart biosimilar medicinal product; the reference product is NovoRapid (see note 2).
   
2. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
3. Trurapi has a lower acquisition cost in comparison to NovoRapid.
4. Transferring a patient to another type or brand of insulin should be done under strict medical supervision. Changes in strength, brand, type, origin (animal, human, human insulin analogue) and/or method of manufacture may result in the need for a change in dose. Close metabolic monitoring is recommended during the transition and in the initial weeks thereafter.
5. Note for community pharmacy: for information on ordering Trurapi insulin, see here.

NovoRapid

(Insulin aspart)

• Vial (10ml) 100units/ml (£14.08 = 10ml)
• Cartridge (3ml) 100units/ml (£28.31 = 5 cartridges)
• FlexPen pre-filled disposable injection device (3ml) 100units/ml (£30.60 = 5 devices)
• PumpCart cartridge (1.6ml) 100units/ml (£15.10 = 5 cartridges)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required. In addition, NovoRapid is a biological medicine with licensed biosimilar medicines (Trurapi, above).
   
2. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.

Fiasp

(Insulin aspart)

• Vial (10ml) 100units/ml (£14.08 = 10ml)
• Cartridge (3ml) 100units/ml (£28.31 = 5 cartridges)
• FlexTouch pre-filled disposable injection device (3ml) 100units/ml, (£30.60 = 5 devices)

Notes

1. Medicines Supply Notification 04 March 2024 (MSN/2024/027): 
   1. Fiasp FlexTouch 100units/ml pre-filled pens will be out of stock from April 2024 until September 2025 (date updated from the SPS Medicines Supply Tool).
   2. No new patients should be initiated on Fiasp FlexTouch.
   3. Consider prescribing Fiasp Penfill cartridges, which can support increased demand, taking into account the patient’s manual dexterity and ability to use the new device correctly. Prescribe a Novo Nordisk insulin delivery system (e.g. NovoPen 6 [1 unit increments] or NovoPen Echo Plus [½ unit increments]) and appropriate needles.
   4. Seek specialist advice on alternative insulin if Fiasp Penfill cartridges are not suitable.
   5. Provide counselling and training for all patients with a new device, including signposting to training videos, as well as potential need for closer monitoring of blood glucose levels.
2. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
3. Fiasp is a new formulation of insulin aspart with faster initial absorption after subcutaneous administration.
4. Patients should be aware that hypoglycaemia may occur earlier after the use of Fiasp when compared to other mealtime insulins.
5. When administered subcutaneously, Fiasp should be administered in the abdominal wall or the upper arm. Lower exposure levels are obtained if administered in the thigh.

Insulin lispro

Admelog

(Insulin lispro)

• Vial (10ml) 100units/ml (£14.12 = 10ml)
• Cartridge (3ml) 100units/ml (£21.23 = 5 cartridges)
• Solostar prefilled disposable injection device (3ml) 100units/ml (£22.10 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required. In addition, Admelog is an insulin lispro biosimilar medicinal product; the reference product is Humalog (see note 2).
   
2. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
3. Admelog has a lower acquisition cost in comparison to Humalog.
4. Transferring a patient to another type or brand of insulin should be done under strict medical supervision. Changes in strength, brand, type, origin (animal, human, human insulin analogue) and/or method of manufacture may result in the need for a change in dose. Close metabolic monitoring is recommended during the transition and in the initial weeks thereafter.
5. Note for community pharmacy: for information on ordering Admelog insulin, see here.

Humalog

(Insulin lispro)

• Vial (10ml) 100units/ml (£16.61 = 10ml)
• Cartridge (3ml) 100units/ml (£28.31 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£29.46 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required. In addition, Humalog is a biological medicine with licensed biosimilar medicines (Admelog, above).
   
2. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.

Lyumjev

(Insulin lispro)

• Vial (10ml) 100units/ml (£16.61 = 10ml)
• Cartridge (3ml) 100units/ml (£28.31 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£29.46 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Lyumjev is a new formulation of insulin lispro with faster initial absorption after subcutaneous administration.
3. Lyumjev is licensed for use in adults.
4. Patients should be aware that hypoglycaemia may occur earlier after the use of Lyumjev when compared to other mealtime insulins.
5. When administered subcutaneously, Lyumjev should be administered into the abdomen, upper arm, thigh or buttocks.

Insulin glulisine

Apidra

(Insulin glulisine)

• Vial (10ml) 100units/ml (£16.00 = 10ml)
• Cartridge (3ml) 100units/ml (£28.30 = 5 cartridges)
• SoloStar pre-filled disposable injection device (3ml) 100units/ml, (£28.30 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

Soluble insulin

Soluble insulins onset of action is about 30 minutes, duration about 8 hours with peak action at about 4 hours.

Actrapid

(Soluble insulin)

• Vial (10ml) 100units/ml (£7.48 = 10ml)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

Humulin S

(Soluble insulin)

• Vial (10ml) 100units/ml (£15.68 = 10ml)
• Cartridge (3ml) 100units/ml (£19.08 = 5 cartridges)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

6.1.1.2 Intermediate and long-acting insulins

Isophane or NPH (Neutral Protamine Hagedorn) insulins are the most reliable intermediate acting insulins, onset of 1-2 hours, and duration of around 12-15 hours. Zn insulins (mixed and crystalline) onset, peak activity and duration vary.

Specialist Pharmacy Service (07 July 2023): Insulins able to support switching from GLP-1 receptor agonists. To ensure the supply chain remains stable for the whole population of people with type 1 and type 2 diabetes requiring insulin, the following insulins are currently able to support insulin initiation for patients unable to obtain GLP-1 receptor agonists:

• Humulin I KwikPen (insulin isophane) 100units/ml pre-filled disposable device (see entry below)
• Humulin M3 KwikPen (biphasic insulin isophane) 100units/ml pre-filled disposable device (see entry below)

Other intermediate-acting and mixed insulins are not able to support switching from a GLP-1 receptor agonist. See below for information on long-acting analogues.

Isophane insulin (NPH)

Insulatard

(Isophane insulin)

• Vial (10ml) 100units/ml (£7.48 = 10ml)
• Cartridge (3ml) 100units/ml (£22.90 = 5 cartridges)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Medicines Supply Notification 21 March 2024 (MSN/2024/032): 
   1. Insulatard InnoLet 100units/ml pre-filled disposable devices are being discontinued with remaining stock exhausted by the end of May 2024.
   2. Humulin I KwikPen (insulin isophane) 100units/ml pre-filled pens remain available and can support increased demand.
   3. Insulatard Penfill 100units/ml cartridges and 100units/ml Insulatard vials remain available but cannot support any increased demand.
   4. Identify and review patients currently prescribed Insulatard InnoLet.
   5. Consider prescribing Humulin I KwikPen pre-filled pens where appropriate, taking into account the patient’s manual dexterity, vision, ability to use new device correctly, and whether support is required with administering the dose.
   6. Seek advice from specialist diabetes team on management options if the above option is not considered suitable.
   7. Provide counselling and training for all patients with a new device, including signposting to training videos, as well as potential need for closer monitoring of blood glucose levels.

Humulin I

(Isophane insulin)

• Vial (10ml) 100units/ml (£15.68 = 10ml)
• Cartridge (3ml) 100units/ml (£19.08 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£21.70 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

Biphasic insulins

Humulin M3

(Biphasic isophane insulin)

• Vial (10ml) 100units/ml (£15.68 = 10ml)
• Cartridge (3ml) 100units/ml (£19.08 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£21.70 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Contains recombinant human insulin analogue (30% soluble insulin / 70% isophane insulin)

NovoMix 30

(Biphasic insulin aspart)

• Cartridge (3ml) 100units/ml (£28.79 = 5 cartridges)
• FlexPen pre-filled disposable injection device (3ml) 100units/ml (£29.89 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Contains recombinant human insulin analogue (30% soluble insulin aspart / 70% protamine-crystallised insulin aspart)

Humalog Mix25

(Biphasic insulin lispro)

• Vial (10ml) 100units/ml (£16.61 = 10ml)
• Cartridge (3ml) 100units/ml (£29.46 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£30.98 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Contains recombinant human insulin analogue (25% insulin lispro solution / 75% insulin lispro protamine)

Humalog Mix50

(Biphasic insulin lispro)

• Cartridge (3ml) 100units/ml (£29.46 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£30.98 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Contains recombinant human insulin analogue (50% insulin lispro solution / 50% insulin lispro protamine)

Long-acting analogues

Specialist Pharmacy Service (07 July 2023): Insulins able to support switching from GLP-1 receptor agonists. To ensure the supply chain remains stable for the whole population of people with type 1 and type 2 diabetes requiring insulin, the following insulins are currently able to support insulin initiation for patients unable to obtain GLP-1 receptor agonists:

• Abasaglar KwikPen (insulin glargine) 100units/ml pre-filled disposable device (see entry below)
• Toujeo Solostar (insulin glargine) 300units/ml, pre-filled disposable device (this is a high strength insulin which should only be initiated following specialist input. Refer to notes under entry below)

Other long-acting analogues are unable to support switching from GLP-1 receptor agonists.

Insulin glargine

Prescribe by brand. There are three insulin glargine entries below. Abasaglar is a biosimilar insulin glargine, the reference insulin is Lantus (insulin glargine). Toujeo is a high-strength insulin glargine.

Abasaglar

(Insulin glargine)

• Cartridge (3ml) 100units/ml (£35.28 = 5 cartridges)
• KwikPen pre-filled disposable injection device (3ml) 100units/ml (£35.28 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required. In addition, abasaglar is an insulin glargine biosimilar medicinal product; the reference product is Lantus (see note 2).
2. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
3. Transferring a patient to another type or brand of insulin should be done under strict medical supervision. Changes in strength, brand, type, origin (animal, human, human insulin analogue) and/or method of manufacture may result in the need for a change in dose. Close metabolic monitoring is recommended during the transition and in the initial weeks thereafter.

Lantus

(Insulin glargine)

• Vial (10ml) 100units/ml (£25.69 = 10ml)
• Cartridge (3ml) 100units/ml (£34.75 = 5 cartridges)
• SoloStar pre-filled disposable injection device (3ml) 100units/ml (£34.75 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required. In addition, Lantus is a biological medicine with licensed biosimilar medicines (abasaglar, above).
2. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.

Toujeo

(Insulin glargine)

• SoloStar pre-filled disposable injection device (1.5ml) 300units/ml (£32.14 = 3 devices) (dose increments are steps of 1 unit)
• DoubleStar pre-filled disposable injection device (3ml) 300units/ml (£64.27 = 3 devices) (dose increments are steps of 2 units)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Toujeo should only be initiated following specialist input
3. Toujeo, Lantus, and Abasaglar are not bioequivalent and are not directly interchangeable
4. Toujeo contains 3 times the amount of active pharmaceutical ingredient per ml compared to Lantus
5. SoloStar pre-filled pens contain 1.5ml (equivalent to 450 units), 1-80 units per single injection, in steps of 1 unit
6. DoubleStar pre-filled pens contain 3ml (equivalent to 900 unit), 2-160 units per single injection, in steps of 2 units
7. Care should be taken to ensure patients and carers are aware that the dose increments are in 2 units of insulin for the Toujeo DoubleStar product. In general, all patients and carers should be trained to check ‘the number of units’ dialled up on a pre-filled pen and not to rely on counting the number of clicks
8. Particular care needs to be taken for those patients who are visually impaired
9. The potency is stated in units. These units are exclusive to Toujeo and are not the same as IU or the units used to express the potency of other insulin analogues
10. When changing from SoloStar to DoubleStar the same dose can be used. But if the patient's previous dose was an odd number (e.g. 23 units) then the dose must be increased or decreased by 1 unit (e.g. 24 or 22 units)
11. Refer to the manufacturer's Summary of Product Characteristics (SPC) for guidance on switching between basal insulins. Close metabolic monitoring is recommended during the switch and in the initial weeks thereafter
12. Educational risk minimisation materials can be found here

Insulin detemir

Levemir

(Insulin detemir)

• Cartridge (3ml) 100units/ml (£42.00 = 5 cartridges)
• FlexPen pre-filled disposable injection device (3ml) 100units/ml (£42.00 = 5 devices)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required.
2. Medicines Supply Notification 21 March 2024  (MSN/2024/033): 
   1. Levemir InnoLet 100units/ml pre-filled disposable devices are being discontinued with remaining stock exhausted by the end of May 2024.
   2. Levemir FlexPen 100units/ml pre-filled pens and Levemir Penfill 100units/ml cartridges remain available and can support increased demand.
   3. Identify and review patients currently prescribed Levemir InnoLet.
   4. Consider prescribing Levemir FlexPens or Levemir Penfill cartridges where appropriate, taking into account the patient’s manual dexterity, vision, ability to use new device correctly, and whether support is required with administering the dose.
   5. When prescribing Levemir Penfill cartridges, prescribe a Novo Nordisk insulin delivery system (e.g. NovoPen 6 [1 unit increments] or NovoPen Echo Plus [½ unit increments]) and appropriate needles.
   6. Seek advice from specialist diabetes team on management options if the above options are not considered suitable.
   7. Provide counselling and training for all patients with a new device, including signposting to training videos, as well as potential need for closer monitoring of blood glucose levels.

Insulin degludec

Tresiba

(Insulin degludec)

• Cartridge (3ml) 100units/ml (£46.60 = 5 cartridges)
• FlexTouch pre-filled disposable injection device (3ml) 100units/ml (£46.60 = 5 devices)
• FlexTouch pre-filled disposable injection device (3ml) 200units/ml (£55.92 = 3 devices)

Indications

• Adult patients with type 1 diabetes who experience frequent or severe hypoglycaemia
• Children and adolescents with type 1 diabetes who have a history of diabetic ketoacidosis and/or hyperglycaemia (blood glucose exceeding 14.0 mmol/L) with capillary blood ketones exceeding 1.5 mmol/L

Notes

1. Direct Healthcare Professional Communication March 2024: Tresiba FlexTouch - Update on Supply Shortage 
   1. Tresiba FlexTouch 100units/ml pre-filled pens will be out of stock until December 2024.
   2. Ensure that patients currently using Tresiba FlexTouch 100units/ml pens are supported to change to an alternative treatment as soon as possible. Refer to the advice provided in the Medicines Shortage Notification MSN/2023/053 (see note 2) and the National Patient Safety Alert (see note 3).
      
2. Medicine Supply Notification 24 May 2023 (MSN/2023/053): Tresiba (insulin degludec) FlexTouch 100units/ml solution for injection 3ml pre-filled pens
   1. Tresiba FlexTouch 100units/ml pens will be out of stock from August 2023 until December 2024
   2. No new patients should be initiated on Tresiba FlexTouch 100units/ml pens
   3. Consider prescribing Tresiba Penfill cartridges, taking into account the patient’s manual dexterity and ability to use the new device correctly. Prescribe a Novo Nordisk insulin delivery system (e.g. NovoPen 6 [1 unit increments] or NovoPen Echo Plus [½ unit increments]) and appropriate needles
   4. Seek specialist advice on alternative insulin if Tresiba Penfill cartridges are not suitable
   5. Provide counselling and training for all patients with a new device, including signposting to training videos, as well as potential need for closer monitoring of blood glucose levels.
3. National Patient Safety Alert (8th December 2023): Potential for inappropriate dosing of insulin when switching insulin degludec (Tresiba) products
   1. All providers must ensure that patients who have been switched to Tresiba (insulin degludec) FlexTouch 200units/ml solution for injection 3ml prefilled pens are made aware that Tresiba FlexTouch pen delivery devices dial up in unit increments rather than volume and no dose change is necessary
   2. Primary care providers should continue to follow the advice in the MSN (see note 1 above, the NPSA also highlights the information in notes 1c & 1e above).
      1. For a small cohort of patients unable to use Tresiba 100units/ml Penfill cartridges a switch to Tresiba FlexTouch 200units/ml prefilled pens may be necessary, clinicians should not adjust the dose of insulin.
   3. Secondary care providers should avoid initiating patients on Tresiba (insulin degludec) FlexTouch 200units/ml prefilled pens due to supply constraints. If unable to switch to Tresiba 100units/ml Penfill cartridges, consider initiating a patient on an alternative long-acting insulin
4. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
5. The routine commissioning of insulin degludec is not accepted in Devon for the treatment of Type 2 diabetes (see Commissioning Policy for more information).
6. MHRA Drug safety update April 2013: Insulin degludec (Tresiba▼): Available in additional higher strength. Care needed to minimise risk of error, including training for patients (refer to MHRA update for further details)
   1. When prescribing insulin degludec, ensure that the strength is included on the prescription.
   2. Do not convert (ie, recalculate) doses when transferring patients from one strength of insulin degludec to another—the pen device shows the number of units of insulin to be injected irrespective of strength.

Other insulins

Highly purified animal insulin - porcine

For safety the insulin prescription for any person should be consistent, stating the species (if not human), the proprietary name, whether a vial, cartridge or pen is needed and, for premixed insulins, the ratio of the two types of insulin.

Hypurin Porcine Isophane

(Porcine isophane insulin)

• Vial (10ml) 100units/ml (£39.39 = 10ml)
• Cartridge (3ml) 100units/ml (£59.08 = 5 cartridges)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

Hypurin Porcine 30/70 Mix

(Biphasic porcine isophane insulin)

• Vial (10ml) 100units/ml (£39.39 = 10ml)
• Cartridge (3ml) 100units/ml (£59.08 = 5 cartridges)

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
2. Contains porcine insulin (30% insulin soluble porcine / 70% insulin isophane porcine)

6.1.1.3 Hypodermic equipment

Hypodermic insulin injection pens

Reusable pens for use with insulin cartridges.

All injection devices now need to be prescribed and are no longer free of charge.

AllStar Pro

• Increments of 1unit, up to 80units (£25.00 = 1 device)
• For use with Admelog, Apidra, Trurapi, Lantus 3ml cartridges
• AllStar Pro replaces the discontinued ClikSTAR

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

Autopen 24

• Increments of 1unit, up to 21units (£17.93 = 1 device)
• Increments of 2units, up to 42units (£17.93 = 1 device)
• For use with Apidra and Lantus 3ml cartridges

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

Autopen Classic

• Increments of 1unit, up to 21units (£18.20 = 1 device)
• Increments of 2units, up to 42units (£18.20 = 1 device)
• For use with 3ml Lilly and Wockhardt cartridges

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

HumaPen Savvio

• Increments of 1unit, up to 60units (£27.01 = 1 device)
• For use with 3ml Humulin and Humalog cartridges

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required

NovoPen Echo Plus

• Increments of 0.5units, up to 30units (£26.86 = 1 device)
• For use with 3ml Novo Nordisk cartridges

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required.

NovoPen 6

• Increments of 1unit, up to 60units (£26.86 = 1 device)
• For use with 3ml Novo Nordisk cartridges

Notes

1. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required.

Pen needles

Following national guidance from NHS England, insulin pen needles that cost >£5 per 100 needles are not recommended for use. Some pen needles will fit all major insulin delivery pen devices, and the most cost-efficient needles should be used first line. Click here for more information. Prescribers should not initiate insulin pen needles that cost >£5 per 100 needles for any new patient.

GlucoRx CarePoint, CarePoint Ultra, and FinePoint;BD Viva; and Omnican Fine needles are all compatible with UK pen devices (October 2019).

The local diabetes specialists recommend that 4mm/ 5mm/ 6mm pen needles should be used in all patients, regardless of BMI.

8mm and 12mm needles are not recommended because there is a tendency to inject into muscle rather than subcutaneous tissue, which results in too rapid absorption of insulin and a risk of hypoglycaemia.

GlucoRx CarePoint

• 4mm/31gauge (£2.75 = 100 needles)
• 5mm/31gauge (£2.75 = 100 needles)
• 6mm/31gauge (£2.75 = 100 needles)

GlucoRx CarePoint Ultra

• 4mm/32gauge (£2.75 = 100 needles)

BD Viva

• 4mm/32gauge (£3.59 = 90 needles)
• 5mm/31gauge (£3.59 = 90 needles)
• 6mm/31gauge (£3.59 = 90 needles)

Omnican Fine

• 4mm/32gauge (£4.10 = 100 needles)
• 5mm/32gauge (£4.10 = 100 needles)
• 6mm/32gauge (£4.10 = 100 needles)

GlucoRx FinePoint

• 4mm/31gauge (£4.50 = 100 needles)
• 5mm/31gauge (£4.50 = 100 needles)
• 6mm/31gauge (£4.50 = 100 needles)

Safety needles

Where it is not reasonably practicable to avoid the use of medical sharps, the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 require healthcare employers (or their contractors) to substitute traditional, unprotected medical sharps with a 'safer sharp'. It is therefore expected that healthcare employers will provide safety needles to workers where there is a risk of needle stick injury.

Safety needles should not be prescribed on FP10, except in exceptional circumstances such as:

• Non-healthcare employed, third party injectors e.g. school staff who administer insulin for pupils
• Patients in whom needle phobia is a barrier to injecting

If these are to be prescribed by GPs, the most cost-efficient choices are GlucoRx Safety pen needles 5mm/30g (£12.95 per 100) or Microdot Max Safety Pen Needles 5mm/30g (£12.89 per 100). BD AutoShield Duo 5mm/30g are not recommended due to their high cost (£30.41 per 100).

Other equipment

Needle Clipping (Chopping) Device

• (£1.61)

Sharpsguard

• 1 litre (£1.13)

Sharpsafe

• 1 litre (£1.07)