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WHICH INSULIN AND REGIME? The preferred insulin type and regime of insulin to be commenced will be influenced by the level of glycaemic control at the point the individual agrees to commence insulin, but the actual regime commenced will be dependent on what the individual is willing to try, and an initial compromise that results in the successful introduction of insulin therapy may need to be accepted. The national recommendations are that insulin is added to the

current dose of metformin and sulfonylurea currently being taken by the patient, with the sulfonylurea dose being reviewed if hypoglycaemia develops.2 Guidelines from NICE2

clearly outline the options in relation to commencing insulin therapy in type 2 diabetes

Initial insulin options 1. Once-daily isophane (NPH) insulin at bedtime if HbA1c <75mmol/mol (9.0%).

2. Once-daily long-acting insulin analogue if third party required eg, district nurse.

3. Consider twice-daily human pre-mixed insulin if HbA1c >75mmol/mol.

4. Consider twice-daily pre-mixed analogue insulin if HbA1c >75mmol/mol and if injecting immediately pre-meals is preferred.

WHO SHOULD COMMENCE INSULIN THERAPY? All healthcare professionals involved in the management of individuals with type 2 diabetes should understand the indications for insulin therapy and be able to discuss insulin as a treatment option and refer appropriately to the relevant local service for insulin initiation.3 Insulin therapy should only been commenced by health care

professionals that have undertaken training in relation to initiating insulin therapy and demonstrated competence in line with the integrated career and competency for diabetes nurses.3,4

HOW SHOULD INSULIN THERAPY BE COMMENCED? Education is the key to successfully implementation of insulin therapy. All individuals commencing insulin demonstrate some degree of anxiety and a clear structured education plan to address all key areas in a systematic manner will help to address and alleviate any reservations and anxieties. Education needs can be addressed either individually or as part of a group.

POTENTIAL AREAS OF CONCERN When insulin therapy is discussed the three main areas of concern expressed by individuals are inability/fear of self-injecting, hypoglycaemia and weight gain. Needle phobia is a relatively rare phenomena but fear of

self-injecting is very real for the vast majority of people. Simply showing an individual an insulin pen device, appropriate pen needle and potential injection sites will alleviate these fears in the majority of cases, with the remainder responding positively to a dummy injection using an empty device. In individuals with genuine needle phobia, referral to the local diabetes specialist nursing team is appropriate. Hypoglycaemia is significantly less of an issue in type 2

diabetes than type 1 diabetes due to the insulin resistant nature of the type 2 diabetes, but it remains a high level concern to the individual with diabetes especially when the need for insulin

therapy is explored. Education relating to hypoglycaemia should be explored long before the need for insulin therapy is identified. Sulfonylurea therapy caries a similar risk of hypoglycaemia to insulin in type 2 diabetes, and education should therefore begin when this oral therapy is being considered, and revisited when the need for insulin is identified. The risk of weight gain is a common anxiety expressed by many

individuals as a reason for not commencing insulin. The UKPDS study found that study participants gained approximately 3kg in weight following the introduction of insulin therapy and 1.8kg when commenced on a sulfonylurea6

so although weight gain can and

does occur with insulin it is not the only diabetes treatment that is associated with this problem. Exploration of strategies to minimise weight gain, such as

reviewing levels of physical activity, patterns of eating and meal sizes, should be included in education around initiating insulin therapy.

WHAT IS THE CORRECT DOSE OF INSULIN? Individual insulin requirements vary from person to person, most individuals with insulin requiring type 2 diabetes will need at minimum of 0.5 units per kg per day, but some may require in excess of two units per kg per day.7

When commencing insulin

therapy to alleviate anxiety in relation to hypoglycaemia lower than anticipated, insulin doses are initiated, but for the introduction of

‘Needle phobia is a relatively rare phenomena but fear of self- injecting is very real for the vast majority of people’

insulin to be effective active dose titration must occur. Insulin dose titration is based on the of individuals SBGM results. Dose increases of a minimum of two units or 10% of dose are made if the SBGM results are above the agreed target level.

INSULIN SAFETY Insulin frequently features in the top ten high alert medicines worldwide in an attempt to address some of the insulin errors that occurs a number of safety strategies are being promoted within the UK.8,9

NHS Diabetes host the safe use of insulin e-learning

package which should be completed by all health care profession- als involved in the management of individuals with diabetes treated with insulin, and an essential training opportunity for any health- care professional involved in initiating insulin therapy. It highlights a number of issues relevant to primary care practitioners, in particular the correct naming of insulin in documentation and the avoidance of using abbreviations when writing insulin doses - units should always be written in full.8 To address problems with patients being administered or

dispensed the incorrect insulin, a national program is being implemented for August 2012 to ensure that all individuals treated with insulin have appropriate documentation that clearly states the correct name of the insulin preparation they are using, which they are encouraged to carry with them at all times.9

CONCLUSION Insulin therapy is an area of diabetes care that generates a significant amount of anxiety amongst healthcare professionals, but as the Nursing in Practice March/April 2012 41

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