6.1.1 Insulins

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):

  • Northern Devon Healthcare NHS Trust: Diabetes Specialist Nurses, available from 8am to 5.30pm Monday to Friday on 01271 3222726
  • Royal Devon & Exeter NHS Foundation Trust: Duty Consultant Monday to Friday 2pm-2.45pm 07818 002363 or email on rh8.diabetesadvice@nhs.net
  • Royal Devon & Exeter NHS Foundation Trust: 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) – see below
  • 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.

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

6.1.1.1 Short-acting insulins

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), 100 units per 1ml (£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), 100 units per 1ml (£15.68 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£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
Insuman® Rapid

(Soluble insulin)

  • Cartridge (3ml), 100 units per 1ml (£17.50 = 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

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.

NovoRapid®

(Insulin aspart)

  • Vial (10ml), 100 units per 1ml (£14.08 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£28.31 = 5 cartridges)
  • FlexPen® prefilled disposable injection device (3ml), 100 units per 1ml (£30.60 = 5 devices)
  • PumpCart® cartridge (1.6ml), 100 units per 1ml (£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
Humalog®

(Insulin lispro)

  • Vial (10ml) 100 units per 1ml (£16.61 = 1ml)
  • Cartridge (3ml), 100 units per 1ml (£28.31 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device (3ml), 100 units per 1ml (£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
Apidra®

(Insulin glulisine)

  • Vial (10ml), 100 units per 1ml (£16.00 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£28.30 = 5 cartridges)
  • SoloStar® prefilled disposable injection device (3ml), 100 units per 1ml, (£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
Fiasp®

(Insulin aspart)

  • Vial (10ml), 100 units per 1ml (£14.08 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£28.31 = 5 cartridges)
  • FlexTouch® prefilled disposable injection device (3ml), 100 units per 1ml, (£30.60 = 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. Fiasp is a new formulation of insulin aspart with faster initial absorption after subcutaneous administration.
  3. Fiasp is licensed for use in adults.
  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.

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.

Isophane insulin (NPH)

Insuman® Basal

(Isophane insulin)

  • Cartridge (3ml), 100 units per 1ml (£17.50 = 5 cartridges)
  • Solostar® prefilled disposable injection device (3ml), 100 units per 1ml (£19.80 = 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
Insulatard®

(Isophane insulin)

  • Vial (10ml), 100 units per 1ml (£7.48 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£22.90 = 5 cartridges)
  • InnoLet® prefilled disposable injection device (3ml), 100 units per 1ml (£20.40 = 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
Humulin I®

(Isophane insulin)

  • Vial (10ml), 100 units per 1ml (£15.68 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£19.08 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device (3ml), 100 units per 1ml (£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), 100 units per 1ml (£15.68 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£19.08 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device (3ml), 100 units per 1ml (£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)
Insuman Comb 25®

(Biphasic isophane insulin)

  • Cartridge (3ml), 100 units per 1ml (£17.50 = 5 cartridges)
  • SoloStar® prefilled disposable injection device (3ml), 100 units per 1ml (£19.80 = 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% dissolved insulin / 75% crystalline protamine insulin)
NovoMix30®

(Biphasic insulin aspart)

  • Cartridge (3ml), 100 units per 1ml (£28.79 = 5 cartridges)
  • FlexPen® prefilled disposable injection device (3ml), 100 units per 1ml (£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), 100 units per 1ml (£16.61 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£29.46 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device (3ml), 100 units per 1ml (£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), 100 units per 1ml (£29.46 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device (3ml), 100 units per 1ml (£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

Insulin glargine
Abasaglar®

(Insulin glargine)

  • Cartridge (3ml), 100 units per 1ml (£35.28 = 5 cartridges)
  • KwikPen® prefilled disposable injection device (3ml), 100 units per 1ml (£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. Abasaglar has a lower acquisition cost in comparison to Lantus.
  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.
Lantus®

(Insulin glargine)

  • Vial (10ml), 100 units per 1ml (£27.92 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£37.77 = 5 cartridges)
  • SoloStar® prefilled disposable injection device (3ml), 100 units per 1ml (£37.77 = 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® prefilled disposable injection device (1.5ml), 300 units per 1ml (£33.13 = 3 devices)

Notes

  1. This high-strength insulin glargine should only be used in patients with large daily insulin requirements to reduce the number or volume of injections, particularly patients with type 2 diabetes who are insulin resistant.
  2. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
  3. Toujeo should only be initiated following specialist input.
  4. Toujeo contains 3 times the amount of active pharmaceutical ingredient per ml compared to Lantus.
  5. Each pre-filled pen contains 1.5ml (equivalent to 450 units). 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.
  6. 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.
Insulin detemir
Levemir®

(Insulin detemir)

  • Cartridge (3ml), 100 units per 1ml (£42.00 = 5 cartridges)
  • FlexPen® prefilled disposable injection device (3ml), 100 units per 1ml (£42.00 = 5 devices)
  • InnoLet® prefilled disposable injection device (3ml), 100 units per 1ml (£44.85 = 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
Insulin degludec
Tresiba®

(Insulin degludec)

  • Cartridge (3ml), 100 units per 1ml (£46.60 = 5 cartridges)
  • FlexTouch® prefilled disposable injection device (3ml), 100 units per 1ml (£46.60 = 5 devices)
  • FlexTouch® prefilled disposable injection device (3ml), 200 units per 1ml (£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. Prescribe by brand. Patient familiarity with one brand is important; instructions for use vary between preparations and patient training is required
  2. The routine commissioning of insulin degludec is accepted in Devon for the treatment of patients with type 1 diabetes who meet specific criteria (See Commissioning Policy for more information)
  3. The routine commissioning of insulin degludec is not accepted in Devon for the treatment of Type 2 diabetes (see Commissioning Policy for more information).
  4. 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.

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), 100 units per 1ml (£31.30 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£46.95 = 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), 100 units per 1ml (£31.30 = 10ml)
  • Cartridge (3ml), 100 units per 1ml (£46.95 = 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

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/31 gauge (£2.75 = 100 needles)
  • 5mm/31 gauge (£2.75 = 100 needles)
  • 6mm/31 gauge (£2.75 = 100 needles)
GlucoRx CarePoint Ultra®
  • 4mm/32 gauge (£2.75 = 100 needles)
BD Viva®
  • 4mm/32 gauge (£3.55 = 90 needles)
  • 5mm/31 gauge (£3.55 = 90 needles)
  • 6mm/31 gauge (£3.55 = 90 needles)
Omnican Fine®
  • 4mm/32 gauge (£3.95 = 100 needles)
  • 5mm/32 gauge (£3.95 = 100 needles)
  • 6mm/32 gauge (£3.95 = 100 needles)
GlucoRx Finepoint®
  • 4mm/31 gauge (£4.50 = 100 needles)
  • 5mm/31 gauge (£4.50 = 100 needles)
  • 6mm/31 gauge (£4.50 = 100 needles)

Other equipment

Needle Clipping (Chopping) Device
  • (£1.48)
Sharpsguard
  • 1 litre (£0.86)
Sharpsafe
  • 1 litre (£0.85)

 

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