Insulin therapy
All people with type 1 diabetes will require insulin by injection. In addition women with gestational diabetes may also require insulin injections or continuous infusion. Some people with type 2 diabetes will require insulin as a supplement to their endogenous supplies usually in addition to their oral hypoglycaemics.
The insulin which people with diabetes inject comes from one of two sources, either animal or human insulin.
Animal insulin comes from the pancreas' of pigs or cows whereas human insulin does not come from humans. It is genetically engineered and is identical to the insulin which humans produce. Human insulin analogues are a newer form of insulin.
Different types of insulin
Rapid-acting analogue
- These can be injected five to 15 minutes before eating, when eating or immediately after eating. They last between two and five hours in the body. These are often taken in combination with longer acting insulin.
Short-acting
- These are injected 15 to 30 minutes before a meal and can work for up to eight hours in the body. They are often used in combination with longer-acting insulin.
Medium and longer-acting
- These are injected around 30 minutes before a meal and work over several hours to keep blood glucose under control between meals. They are often used in combination with short-acting insulin.
Long-acting insulin analogues
- These don't have a peak action like other insulins.
Individuals will use different regimes of insulin, depending on a number of factors. The diabetes team and individual will discuss this to tailor the regime to the individual and their lifestyle.
Resources
You will find here links to evidence-based resources which support this topic. You may also want to refer to information about the national service frameworks and strategies across the UK.
Some of the resources on this page are in PDF format - see how to access PDF files.
Guidelines and guidance
Clinical Resource Efficiency Support Team (CREST) (2006) Safe and effective use of insulin in secondary care : recommendations for treating hyperglycaemia in adults (PDF 415KB)
This guideline developed by CREST has been produced to support protocols for tight glucose control in hospitalised patients with diabetes, to minimise the risks of hyperglycaemia and ensure patient safety.
Department of Health (2007) Insulin pump services- report of the insulin pumps working group
This report presents the outcomes of the working group which included clinicians and pump users from across the country looking at what needed to be done to enable local services to deliver the NICE Health Technology Assessment (HTA) on insulin pumps, and reduce variation in pump provision. A range of good practice examples are provided.
Diabetes UK care recommendations (2009) The arm as an injection site
This care recommendation discusses the debate around the suitability of using the arm as an injection site and what needs to be considered if injecting into the arm is necessary.
Diabetes UK position statement (2007) Safe disposal of needles and lancets (sharps)
In this position statement Diabetes UK calls on local councils, health care organisations and service commissioners to work together to ensure free, convenient, safe systems of sharps disposal are implemented locally.
National Patient Safety Agency Alerts (2011) The adult patient’s passport to safer use of insulin
The aim of this alert is to improve patient safety by empowering patients as they take an active role in their treatment with insulin. This will be achieved with a patient information booklet and a patient-held record (the Insulin Passport) which documents the patient’s current insulin products and enables a safety check for prescribing, dispensing and administration. The Insulin Passport will complement existing systems for ensuring key information is accessed across health care sectors.
National Patient Safety Agency Alerts (2010) Safer administration of insulin
This alert from the NPSA, which is published as a Rapid Response Report, describes two common errors in the administration of insulin and also points to insufficient training as a cause for errors. It sets out a number of procedures that need to be actioned to reduce errors.
NHS Clinical Knowledge Summaries: Insulin therapy in type 2 diabetes - management
The NHS Clinical Knowledge Summaries (CKS) are "a reliable source of evidence-based information and practical ‘know-how’ about the common conditions managed in primary and first-contact care". Management of insulin therapy in type 2 diabetes is described using a series of scenarios such as: when to consider insulin; information for people starting insulin; barriers to insulin therapy; intensifying treatment; adverse effects; work, lifestyle and cultural issues. There are also scenarios around different types of insulin treatment.
NHS Diabetes: Safe use of insulin
This area of the NHS Diabetes website brings together information about the administration of insulin with reference to the National Patient Safety Agency Rapid Response Report on safer administration of insulin. Information is arranged under the following headings: the right insulin; the right dose; the right time; the right way; insulin products; insulin devices. Stories describing incidents where insulin had been incorrectly administered are included. Also available here is an e-learning course designed for all health professionals. The course is freely available but you will need to register to access it - see: Safe use of insulin e-learning course.
NICE guidance by topic: Diabetes
This section of the NICE website includes details of all the current guidelines and guidance published by NICE which is relevant to diabetes.
NICE Technology Appraisal (2008) Diabetes - insulin pump therapy: Continuous subcutaneous insulin infusion for the treatment of diabetes (review)
This reviews and re-appraised the use of continuous subcutaneous insulin infusion and provides updated recommendations on its use.
NICE Technology Appraisal (2002) Diabetes (types 1 and 2) - long acting insulin analogues
Recommendations around the use if insulin glargine. The recommendations in this technology appraisal relating to type 2 diabetes have been replaced by recommendations in the Diabetes - type 2 (update) clinical guideline published in May 2008. Please note that the recommendations in this technology appraisal relating to type 1 diabetes have not changed.
Royal College of Nursing (2006) Starting insulin treatment in adults with Type 2 diabetes. RCN guidance for nurses (PDF 255.8KB)
This revised edition of the publication originally issued in 2004 provides guidance on when insulin should be used in type 2 diabetes and a step-by-step guide to starting insulin treatment.
Royal College of Nursing (2006) Advance preparation of insulin syringes for patients to administer at home: RCN guidance for community nurses (PDF 866.3KB)
Provides guidance on professional issues and the practical issues such as premixing insulins and storage of preloaded syringes.
Systematic reviews and evidence summaries
For more information about Cochrane Systematic Reviews, examples of which appear below, visit the page within this resource on the Cochrane Library.
Cochrane Review: 'Human' insulin versus animal insulin in people with diabetes mellitus
The objective of this review was to assess the effects of different insulin species by evaluating their efficacy (in particular glycaemic control) and adverse effects profile (mainly hypoglycaemia).
Cochrane Review: Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus
The authors conclude that "There is some evidence to suggest that CSII may be better than MI for glycaemic control in people with type 1 diabetes. Non-severe hypoglycaemic events do not appear to be reduced with CSII. There is insufficient evidence regarding adverse events, mortality, morbidity and costs".
Cochrane Review: Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus
This review was based on randomised controlled trials with an intervention duration of at least four weeks.
Cochrane Review: Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus
The authors' conclusions for this review are: "Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used".
Cochrane Review: Intermediate acting versus long acting insulin for type 1 diabetes
This review aimed to assess the effects of intermediate acting versus long acting insulin preparations for basal insulin replacement in type 1 diabetic patients.
Cochrane Review: Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus
This review aimed to assess the effects of long-term treatment with long-acting insulin analogues (insulin glargine and insulin detemir) compared to NPH insulin in patients with type 2 diabetes mellitus.
Cochrane Review: Insulin and oral agents for managing cystic fibrosis-related diabetes
This review examined the evidence that, when treated with agents for managing diabetes, people with cystic fibrosis improve their sugar metabolic control resulting in beneficial impact on lung function and the ability to maintain optimal weight.
Other resources
Insulin Dependent Diabetes Trust International
The Insulin Dependent Diabetes Trust is "concerned with listening to the needs of people who live with diabetes, understanding those needs and doing our utmost to offer help and support".
National Prescribing Centre (2007) The role of newer insulins in diabetes. MeReC Bulletin Summary Volume 17 Number 4 June
This summary of an MeRec Bulletin, which is made available on the National Prescribing Centre (NPC) website, considers the evidence supporting the use of the newer insulins and their role in patients with type 1 and type 2 diabetes.
There are separate resources lists for other specific aspects of treatment and lifestyle - see Treatment and lifestyle topics.