INSULINS
Insulins f
IMPORTANT SAFETY INFORMATION
NHS IMPROVEMENT PATIENT SAFETY ALERT: RISK OF SEVERE
HARM AND DEATH DUE TO WITHDRAWING INSULIN FROM PEN
DEVICES (NOVEMBER 2016)
Insulin should not be extracted from insulin pen devices.
The strength of insulin in pen devices can vary by
multiples of 100 units/mL. Insulin syringes have
graduations only suitable for calculating doses of
standard 100 units/mL. If insulin extracted from a pen or
cartridge is of a higher strength, and that is not
considered in determining the volume required, it can
lead to a significant and potentially fatal overdose.lSIDE-EFFECTS
▶Common or very commonOedema
▶UncommonLipodystrophy.skin reactions
SIDE-EFFECTS, FURTHER INFORMATION
OverdoseOverdose causes hypoglycaemia.
lPREGNANCY
Dose adjustmentsDuring pregnancy, insulin requirements
may alter and doses should be assessed frequently by an
experienced diabetes physician.
The dose of insulin generally needs to be increased in
the second and third trimesters of pregnancy.
lBREAST FEEDING
Dose adjustmentsDuring breast-feeding, insulin
requirements may alter and doses should be assessed
frequently by an experienced diabetes physician.
lHEPATIC IMPAIRMENT
Dose adjustmentsInsulin requirements may be decreased
in patients with hepatic impairment.
lRENAL IMPAIRMENTThe compensatory response to
hypoglycaemia is impaired in renal impairment.
Dose adjustmentsInsulin requirements may decrease in
patients with renal impairment and therefore dose
reduction may be necessary.
lMONITORING REQUIREMENTS
▶Many patients now monitor their own blood-glucose
concentrations; all carers and children need to be trained
to do this.
▶Since blood-glucose concentration varies substantially
throughout the day,‘normoglycaemia’cannot always be
achieved throughout a 24 -hour period without causing
damaging hypoglycaemia.
▶It is therefore best to recommend that children should
maintain a blood-glucose concentration of between 4 and
10 mmol/litre for most of the time ( 4 – 8 mmol/litre before
meals and less than 10 mmol/litre after meals).
▶While accepting that on occasions, for brief periods, the
blood-glucose concentration will be above these values;
strenuous efforts should be made to prevent it from falling
below 4 mmol/litre. Patients using multiple injection
regimens should understand how to adjust their insulin
dose according to their carbohydrate intake. Withfixed-
dose insulin regimens, the carbohydrate intake needs to be
regulated, and should be distributed throughout the day to
match the insulin regimen. The intake of energy and of
simple and complex carbohydrates should be adequate to
allow normal growth and development but obesity must be
avoided.
lDIRECTIONS FOR ADMINISTRATIONInsulin is generally
given bysubcutaneous injection; the injection site should
be rotated to prevent lipodystrophy. Injection devices
(‘pens’), which hold the insulin in a cartridge and meter
the required dose, are convenient to use. Insulin syringes
(for use with needles) are required for insulins notavailable in cartridge form, but are less popular with
children and carers. For intensive insulin regimens
multiple subcutaneous injections ( 3 or more times daily)
are usually recommended.
lPRESCRIBING AND DISPENSING INFORMATIONShow
container to patient or carer and confirm the expected
version is dispensed.
UnitsThe word’unit’shouldnotbe abbreviated.
lPATIENT AND CARER ADVICE
HypoglycaemiaHypoglycaemia is a potential problem with
insulin therapy. All patients must be carefully instructed
on how to avoid it; this involves appropriate adjustment of
insulin type, dose and frequency together with suitable
timing and quantity of meals and snacks.
Insulin PassportInsulin Passports and patient information
booklets should be offered to patients receiving insulin.
The Insulin Passport provides a record of the patient’s
current insulin preparations and contains a section for
emergency information. The patient information booklet
provides advice on the safe use of insulin. They are
available for purchase from:
3 M Security Print and Systems Limited
Gorse Street, Chadderton
Oldham
OL 99 QH
Tel:0845 610 1112
GP practices can obtain supplies through their Local Area
Team stores.
NHS Trusts can order supplies fromwww.nhsforms.co.uk/
or by emailing [email protected]. Further information
is available atwww.npsa.nhs.uk.
Driving and skilled tasksDrivers need to be particularly
careful to avoid hypoglycaemia and should be warned of
the problems.INSULINS›RAPID-ACTING
eiiiiFaboveInsulin
(Insulin Injection; Neutral Insulin; Soluble Insulin—
short acting)lINDICATIONS AND DOSE
Diabetes mellitus
▶BY SUBCUTANEOUS INJECTION
▶Child:According to requirements
Hyperglycaemia during illness
▶BY INTRAVENOUS INFUSION
▶Neonate: 0. 02 – 0. 125 unit/kg/hour, dose to be adjusted
according to blood-glucose concentration.▶Child: 0. 025 – 0. 1 unit/kg/hour, dose to be adjusted
according to blood-glucose concentration
Neonatal hyperglycaemia|Neonatal diabetes
▶BY INTRAVENOUS INFUSION
▶Neonate: 0. 02 – 0. 125 unit/kg/hour, dose to be adjusted
according to blood-glucose concentration.Diabetic ketoacidosis|Diabetes during surgery
▶BY INTRAVENOUS INFUSION
▶Child:(consult local protocol)lINTERACTIONS→Appendix 1 : insulins
lSIDE-EFFECTS
▶Rare or very rareRefraction disorder
lDIRECTIONS FOR ADMINISTRATIONShort-acting injectable
insulins can be given by continuous subcutaneous infusion
using a portable infusion pump. This device delivers a
continuous basal insulin infusion and patient-activated
bolus doses at meal times. This technique can be useful for
patients who suffer recurrent hypoglycaemia or marked454 Diabetes mellitus and hypoglycaemia BNFC 2018 – 2019
Endocrine system6