-
Required for all patients who have either:
-
Likely or confirmed type 1 diabetes
-
Previous diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic syndrome (HHS)
-
Symptoms of insulin deficiency (e.g. polyuria, polydipsia, weight loss etc.)
-
Significant hyperglycaemia at any stage (including at diagnosis)
-
Not met glycaemic targets despite lifestyle management + maximal oral/GLP1 agonist therapy
-
Start with weight-based dosing of isophane (Protaphane or Humulin NPH) or glargine (Lantus) insulin
-
0.1 units/kg daily if HbA1c < 64 mmol/mol or BMI < 18 kg/m2 or elderly or renal/liver failure
-
0.2 units/kg daily if HbA1c > 64 mmol/mol and BMI > 18 kg/m2
-
Basal insulin is best administered at night as major role is to counteract hepatic gluconeogenesis
-
Monitor fasting blood glucose (FBG) levels
-
If 3 consecutive FBG levels > 7 mmol/L then increase dose of basal insulin by 10% or 2 units
-
Stop uptitration of basal insulin once any hypoglycaemia OR FBG < 7 mmol/L OR doses reach 0.5 units/kg/day – consider adding rapid acting insulin with meals if above target HbA1c and capillary blood glucose data to show post meal rise
-
Ensure adherence and check injection technique before increasing doses
-
Clear instructions for patients on how to administer and self-titrate basal insulin
-
Essential particularly if concerns over cognitive impairment (medication oversight may be required)
-
Encourage development of a routine with their insulin (e.g. take with dinner or before bed every night)
-
Use BD fine 4 or 5 mm needles as associated with better absorption and less pain/trauma
-
Encourage rotation of injection sites
-
Explain that doses may need to be reduced on the night before and on days of strenuous exercise
-
Once on stable dose of basal insulin repeat HbA1c in 3 months and if above target add in bolus insulin or switch to premixed insulin according to self monitored capillary blood glucose levels
-
The doses of basal insulin may need to be reduced if major changes in diet (e.g. Ramadan) or if new hypoglycaemic agents are added to the regimen
-
Often > 20% dose reductions of basal insulin are required if frequent and/or severe hypoglycaemia