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). Insulin pumps should only be issued by secondary care.

Obtaining advice

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

  • Plymouth Hospitals NHS Trust: GPs can access diabetes consultant advice via bleep by contacting switchboard 01752 202082 Monday – Friday 9am to 5pm. A consultant is also available on the short stay unit (Tamar) on Saturday and Sunday morning if urgent advice required. A DSN may be contacted on 01752 792962
  • Torbay and South Devon NHS Foundation Trust: GPs can access advice from a diabetes consultant or DSN via switchboard 01803 614567 Monday to Friday, 9am to 5pm.

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 100 units per 1ml, 10ml vial (£7.48 = 10ml)
Humulin S®
  • Soluble insulin 100 units per 1ml, 10ml vial (£15.68 = 10ml)
  • Soluble insulin 100 units per 1ml, cartridge 3ml (£19.08 = 5 cartridges)
Insuman® Rapid
  • Soluble insulin 100 units per 1ml, cartridge 3ml (£17.50 = 5 cartridges)

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 100 units per 1ml, 10ml vial (£14.08 = 10ml)
  • Insulin aspart 100 units per 1ml, 3ml cartridge (£28.31 = 5 cartridges)
  • Insulin aspart 100 units per 1ml, 3ml FlexPen® prefilled disposable injection device (£30.60 = 5 device)
  • PumpCart® insulin aspart 100 units per 1ml, 1.6ml cartridge (£15.10 = 5 cartridges)
Humalog®
  • Insulin lispro 100 units per 1ml, 10ml vial (£16.61 = 1ml)
  • Insulin lispro 100 units per 1ml, cartridge 3ml (£28.31 = 5 cartridges)
  • Insulin lispro 100 units per 1ml, 3ml Kwikpen® (£29.46 = 5 devices)
Apidra®
  • Insulin glulisine 100 units per 1ml, 10ml vial (£16.00 = 10ml)
  • Insulin glulisine 100 units per 1ml, cartridge 3ml (£28.30 = 5 cartridges)
  • Insulin glulisine 100 units per 1ml, 3ml SoloStar® prefilled disposable injection device (£28.30 = 5 devices)

6.1.1.2 Intermediate and long-acting insulins

Isophanes 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

Insuman® Basal
  • Isophane insulin 100 units per 1ml, 5ml vial (£5.61 = 5ml)
  • Isophane insulin 100 units per 1ml, 3ml cartridge (£17.50 = 5 cartridges)
  • Isophane insulin 100 units per 1ml, 3ml Solostar® prefilled disposable injection device (£19.80 = 5 devices)
Insulatard®
  • Isophane insulin 100 units per 1ml, 10ml vial (£7.48 = 10ml)
  • Isophane insulin 100 units per 1ml, cartridge 3ml (£22.90 = 5 cartridges)
  • Innolet® prefilled disposable injection device isophane insulin 100 units per 1ml, 3ml (£20.40 = 5 devices)
Humulin I®
  • Isophane insulin 100 units per 1ml, 10ml vial (£15.68 = 10ml)
  • Isophane insulin 100 units per 1ml, cartridge 3ml (£19.08 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device Isophane insulin 100 units per 1ml, 3ml (£21.70 = 5 devices)

Biphasic insulins

Humulin® M3
  • Biphasic isophane insulin 100 units per 1ml, 10ml vial (£15.68 = 10ml)
  • Biphasic isophane insulin 100 units per 1ml, cartridge 3ml (£19.08 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device Biphasic isophane insulin 100 units per 1ml, 3ml (£21.70 = 5 devices)
Insuman Comb 25®
  • Biphasic isophane insulin 100 units per 1ml, 5ml vial (£5.61 = 5ml)
  • Biphasic isophane insulin 100 units per 1ml, cartridge 3ml (£17.50 = 5 cartridges)
  • SoloStar® prefilled disposable injection device Biphasic isophane insulin 100 units per 1ml, 3ml (£19.80 = 5 devices)
NovoMix30®
  • Biphasic insulin aspart (recombinant human insulin analogue), 30% insulin aspart, 70% insulin aspart protamine, 100 units/ml 100 units per 1ml, cartridge 3ml (£28.79 = 5 cartridges)
  • FlexPen® prefilled disposable injection device Biphasic insulin aspart (recombinant human insulin analogue), 30% insulin aspart, 70% insulin aspart protamine, 100 units/ml 100 units per 1ml, 3ml (£29.89 = 5 devices)
Humalog® Mix25
  • Biphasic insulin lispro (recombinant human insulin analogue), 25% insulin lispro, 75% insulin lispro protamine, 100 units/ml 100 units per 1ml, 10ml vial (£16.61 = 10ml)
  • Biphasic insulin lispro (recombinant human insulin analogue), 25% insulin lispro, 75% insulin lispro protamine, 100 units/ml 100 units per 1ml, cartridge 3ml (£29.46 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device Biphasic insulin lispro (recombinant human insulin analogue), 25% insulin lispro, 75% insulin lispro protamine, 100 units/ml 100 units per 1ml, 3ml (£30.98 = 5 devices)
Humalog® Mix50
  • Biphasic insulin lispro (recombinant human insulin analogue), 50% insulin lispro, 50% insulin lispro protamine, 100 units/ml 100 units per 1ml, cartridge 3ml (£29.46 = 5 cartridges)
  • Kwikpen® prefilled disposable injection device Biphasic insulin lispro (recombinant human insulin analogue), 50% insulin lispro, 50% insulin lispro protamine, 100 units/ml 100 units per 1ml, 3ml (£30.98 = 5 devices)
Insuman Comb 50®
  • Biphasic isophane insulin (human insulin as neutral insulin 50%/ isophane insulin 50%) 100 units per 1ml, Cartridge 3ml (£17.50 = 5 cartridges)

Long-acting analogues

Insulin glargine
Abasaglar®
  • Insulin glargine 100 units per 1ml, cartridge 3ml (£35.28 = 5 cartridges)
  • KwikPen® prefilled disposable injection device insulin glargine 100 units per 1ml, 3ml (£35.28 = 5 devices)

Notes

  1. Abasaglar® is an insulin glargine biosimilar medicinal product; the reference product is Lantus®.
  2. Abasaglar has a lower acquisition cost in comparison to Lantus®.
  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 100 units per 1ml, 10ml vial (£30.68 = 10ml)
  • Insulin glargine 100 units per 1ml, cartridge 3ml (£41.50 = 5 cartridges)
  • SoloStar® prefilled disposable injection device insulin glargine 100 units per 1ml, 3ml (£41.50 = 5 devices)
Toujeo®
  • Insulin glargine 300 units per 1ml, SoloStar® prefilled disposable injection device, 1.5ml (£33.13 = 3 devices)

Notes

  1. This high-strength insulin glargine should only be used in patients with large daily insulin requirements, who would otherwise require two injections at one time per dose, to reduce the number or volume of injections particularly patients with type 2 diabetes who are insulin resistant.
  2. Toujeo® contains 3 times the amount of active pharmaceutical ingredient per ml compared to Lantus®.
  3. 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.
  4. 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 100 units per 1ml, cartridge 3ml (£42.00 = 5 cartridges)
  • FlexPen® prefilled disposable injection device Insulin detemir 100 units per 1ml, 3ml (£42.00 = 5 devices)
  • InnoLet® 3ml prefilled disposable injection device Insulin detemir 100 units per 1ml, 3ml (£44.85 = 5 devices)
Tresiba® (insulin degludec)
  1. The routine commissioning of insulin degludec is not accepted in Devon for the treatment of Type 2 diabetes (see Commissioning Policy for more information).
  2. The routine commissioning of insulin degludec is not accepted in Devon for the treatment of Type 1 diabetes (see Commissioning Policyfor more information). The policy indicates that in exceptional circumstances the Trust-Managed Individual Patient Treatments process can be used for this indication.

Highly purified animal insulin - bovine/porcine

For those patients who require animal insulin the Hypurin® range is available.

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® Bovine Isophane
  • 100 units per 1ml, 10ml vial (£27.72 = 10ml)
  • 100 units per 1ml, cartridge 3ml (£41.58 = 5 cartridges)
Hypurin® Porcine Isophane
  • 100 units per 1ml, 10ml vial (£25.20 = 10ml)
  • 100 units per 1ml, cartridge 3ml (£37.80 = 5 cartridges)
Hypurin® Bovine Protamine Zinc
  • 100 units per 1ml, 10ml vial (£27.72 = 10ml)
Hypurin® Porcine 30/70 Mix
  • 100 units per 1ml, 10ml vial (£25.20 = 10ml)
  • 100 units per 1ml, cartridge 3ml (£37.80 = 5 cartridges)
Hypurin® Bovine Lente
  • 100 units per 1ml, 10ml vial (£27.72 = 10ml)
Hypurin® Bovine Neutral
  • 100 units per 1ml, 10ml vial (£27.72 = 10ml)
  • 100 units per 1ml, cartridge 3ml (£41.58 = 5 cartridges)
Hypurin® Porcine Neutral
  • 100 units per 1ml, 10ml vial (£25.20 = 10ml)
  • 100 units per 1ml, cartridge 3ml (£37.80 = 5 cartridges)

6.1.1.3 Hypodermic equipment

Hypodermic insulin injection pens

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

Autopen® 24
  • Increments of 1 unit, up to 21 units, or increments of 2 units, up to 42 units (£16.47)
  • For use with 3ml Sanofi-Aventis cartridges
Autopen® Classic
  • Increments of 1 unit, up to 21 units, or increments of 2 units, up to 42 units (£16.72)
  • For use with 3ml Lilly and Wockhardt cartridges
ClikSTAR®
  • Increments of 1 unit, up to 80 units (£25.00)
  • For use with 3ml Lantus®, Apidra®, and Insuman® cartridges
HumaPen® Luxura HD
  • Increments of 0.5 units, up to 30 units (£26.82)
  • For use with 3ml Humulin® and Humalog® cartridges
HumaPen® Savvio
  • Increments of 1 unit, up to 60 units (£26.82)
  • For use with 3ml Humulin® and Humalog® cartridges
Novopen® Echo
  • Increments of 0.5 units, up to 30 units (£26.86)
  • For use with 3ml Novo Nordisk cartridges
Novopen® 5
  • Increments of 1 unit, up to 60 units (£26.86)
  • For use with 3ml Novo Nordisk cartridges

Pen needles

BD Viva®, GlucoRxFinePoint®, Microdot Droplet® and Omnican Fine® needles are all compatible with all UK pen devices (May 2016).

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.

BD Viva®
  • 4mm 32G, 5mm 31G (£5.36 = 90 needles)
GlucoRx® Finepoint
  • 4mm 31G, 5mm 31G, 6mm 31G (£5.95 = 100 needles)
Microdot Droplet®
  • 4mm 32G, 6mm 31G (£5.95 = 100 needles)
Omnican Fine®
  • 4mm 31G, 6mm 31G (£5.95 = 100 needles)

 

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