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NICE guidance - choice of insulin therapy in type 2 diabetes

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

initiation of insulin therapy in type 2 diabetes:
- insulin therapy may be indicated
  - when other measures no longer achieve adequate blood glucose control (to HbA1c < 7.5% or other higher level agreed with the individual)
  - when starting insulin therapy, use a structured programme employing active insulin dose titration that encompasses:
    - structured education
    - continuing telephone support
    - frequent self-monitoring
    - dose titration to target
    - dietary understanding
    - management of hypoglycaemia
    - management of acute changes in plasma glucose control
    - support from an appropriately trained and experienced healthcare professional
  - when starting insulin therapy in adults with type 2 diabetes, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies
  - NICE suggest that insulin therapy should be initiated from a choice of a number of insulin types and regimens.
    - preferably begin with human NPH insulin, taken at bed-time or twice daily according to need
      - which insulin to choose?
        initiate insulin therapy from a choice of a number of insulin types and regimens
        begin with human NPH insulin injected at bed-time or twice daily according to need
        consider, as an alternative, using a long-acting insulin analogue (insulin detemir, insulin glargine) if:
        who do not reach their target HbA1c because of significant hypoglycaemia or
        who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached or
        who cannot use the device needed to inject NPH insulin but who could administer their own insulin safely and accurately if a switch to one of the long-acting insulin analogues was made or
        who need help from a carer or healthcare professional to administer insulin injections and for whom switching to one of the long-acting insulin analogues would reduce the number of daily injections
    - when to consider twice-daily biphasic human insulin rather than once daily insulin
      - consider twice-daily biphasic human insulin (pre-mix) regimens in particular where HbA1c is elevated above 9.0%
        however note that a once-daily regimen may be an option when initiating this therapy
        
        consider pre-mixed preparations of insulin analogues rather than pre-mixed human insulin preparations when:
        immediate injection before a meal is preferred, or
        hypoglycaemia is a problem, or
        blood glucose levels rise markedly after meals
    - monitoring if on a once daily insulin regime
      - monitor a person on a basal insulin regimen (NPH insulin or a long-acting insulin analogue [insulin detemir, insulin glargine]) for the need for short-acting insulin before meals (or a pre-mixed insulin preparation)
    - monitor a person using pre-mixed insulin once or twice daily:
      - monitor a person who is using pre-mixed insulin once or twice daily for the need for a further injection of short-acting insulin before meals or for a change to a regimen of mealtime plus basal insulin, based on NPH insulin or long-acting insulin analogues (insulin detemir, insulin glargine), if blood glucose control remains inadequate

Treatment with combinations of medicines including SGLT-2 inhibitors may be appropriate for some people with type 2 diabetes; see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes, dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating type 2 diabetes.

Reference:

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NICE guidance - choice of insulin therapy in type 2 diabetes

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