NICE guidance - insulin therapy in type 2 diabetes

Insulin-based treatment

• for adults with type 2 diabetes starting insulin therapy, provide a structured programme using active insulin dose titration that encompasses:
  • injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites
  • continuing telephone support
  • self-monitoring
  • dose titration to target levels
  • dietary advice
  • the DVLA's Assessing fitness to drive: a guide for medical professionals
  • managing hypoglycaemia
  • managing acute changes in plasma glucose control
  • support from an appropriately trained and experienced healthcare professional
    
    
• for adults with type 2 diabetes starting insulin therapy, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies
  
  
• start insulin therapy for adults with type 2 diabetes from a choice of the following insulin types and regimens:
  • offer neutral protamine Hagedorn (NPH) insulin injected once or twice daily according to need
  • consider starting both NPH and short-acting insulin (particularly if the person's HbA1c is 75 mmol/mol [9.0%] or higher), administered either:
    • separately or
    • as a pre-mixed (biphasic) human insulin preparation
      
      
• consider, as an alternative to NPH insulin, using insulin detemir or glargine if the person: needs assistance to inject insulin, lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes or would otherwise need twice-daily NPH insulin in combination with oral blood glucose lowering drugs
  
  
• consider pre-mixed (biphasic) preparations that include short-acting insulin analogues, rather than pre-mixed (biphasic) preparations that include shortacting human insulin preparations, if:
  • the person prefers injecting insulin immediately before a meal,
  • hypoglycaemia is a problem or
  • blood glucose levels rise markedly after meals
    
    
• consider switching to insulin detemir or insulin glargine from NPH insulin in adults with type 2 diabetes:
  • 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 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
    
    
• monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, insulin detemir or insulin glargine) for the need for short-acting insulin before meals (or a pre-mixed [biphasic] insulin preparation)
  
  
• monitor adults with type 2 diabetes who are on pre-mixed (biphasic) insulin for the need for a further injection of short-acting insulin before meals or for a change to a basal bolus regimen with NPH insulin or insulin detemir or insulin glargine, if blood glucose control remains inadequate
  
  
• ensure the risk of medication errors with insulins is minimised by following Medicines and Healthcare products Regulatory Agency (MHRA) guidance on minimising the risk of medication error with high strength, fixed combination and biosimilar insulin products, which includes advice for healthcare professionals when starting treatment with a biosimilar
  
  
• when starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost
  
  
• only offer a GLP-1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant-led multidisciplinary team
  
  
• monitor people on insulin for the need to change the regimen
  
  
• an SGLT-2 inhibitor in combination with insulin with or without other antidiabetic drugs is an option

For detailed guidance then consult the full guideline (1).

Reference:

• NICE (February 2022). Type 2 diabetes in adults: management