Chris Harrold

SpR Diabetes & Endocrinology

Diabetes is common15% of all inpatients50% of those are on insulin20% of patients experienced an insulin error

National Inpatient survey 2011

NPSA 16th June 2010Right insulinRight doseRight timeRight route

BNF has 25 listed insulins All U100 Does not list Humulin R U500

Short: Hypurin Bovine Normal Hypurin Porcine Normal Actrapid Humulin S Insuman Rapid Novorapid Apidra Humalog

Intermediate & Long: Levemir Lantus Hypurin Bovine Lente Hypurin Bovine Isophane Hypurin Porcine Isophane Insulatard Humulin I Insuman Basal Hypurin Bovine Protamine Zinc

Mixed / Biphasic: Novomix 30 Humalog Mix 25 Humalog Mix 50 Hypurin Porcine 30/70 Humulin M3 Insuman Comb 15 Insuman Comb 25 Insuman Comb 50

Right insulin:Which humulin is this?

Humulin I Humulin 3 Humulin M3

Right insulin: Insulin is the only drug prescribed by brand

name Insulin detemir Insulin aspart Insulin glulisine Insulin lispro

Right DoseAbbreviations “U” and “IU” are NEVER to be

used Can be misread as 0

Deaths have occurred from misreading & mis-administering doses

Right time:Right time for the right insulin

Mixed insulins – Breakfast and evening meal Short / rapid insulins – Mealtimes Long / intermediate – Bedtime (and breakfast) Not always true!

Factors beyond our control (i.e. Nurses)

Right Insulin: Brand name, not generic

Right Dose: Clearly written Changes dated and initialled DO NOT USE “U” or “IU”

Right time: Mixed insulins – Breakfast and evening meal Short / rapid insulins – Mealtimes Long / intermediate – Bedtime (and breakfast)

Right Way: Prefilled (disposable) or 3ml Cartridges

Lantus / Apidra – Solostar Novorapid / Novomix 30 / Levemir – Flexpen Humalog / Humalog Mix – Kwikpen

www.diabetes.nhs.uk/safu_use_of_insulin

Indications: Keto-acidosis – fixed rate infusion Diabetic Ketosis Pre-operative

If no more than one meal will be missed (brief starvation) then manage with adaptations to usual regimen.

Sick patients who are not eating and drinking

General rules: If they can eat and drink they should not be on

VRII Continue long acting insulin (Lantus / Levemir) if

already taking. Should not be stopped except when converting

back to usual treatment (e.g. SC insulin) Give SC insulin (rapid / mixed) with meal, then

stop sliding scale after 30-60 minutes.

Hypoglycaemia “4 is the floor” 15-20g fast carbohydrate Recheck after 15 mins and retreat as needed Replace carbohydrate Look for a cause!

Usually sulfonylureas (dirty drugs) Metformin & gliptins do not cause hypos

If not able to take orally / unconscious IV 10% dextrose (160mls over 10 mins)

Not 50% IM glucagon 1mg (single dose)

HyperglycaemiaType 1 or type 2How high?Why high?

Steroids, sepsis, missed / omitted insulinTreat the patient (not the nurse)

4-6 units of Novorapid (or patients usual fast) Not Actrapid (oxymoron) 1 unit corrects by ~ 3 mmol/l

Look at why and how it can be prevented

Dose AdjustmentWatch for trends and look for causes

Avoid reflex dose adjustments Allow sufficient time to see results

Hyperglycaemia Increase dose of appropriate insulin by 10%

E.g. 20 units 22 units, 60 units 66 units

Hypoglycaemia Reduce does of appropriate insulin by 20%

Renal failure:eGFR <30 is the cut off for:

Metformin Gliclazide

What is safe? Saxagliptin (to eGFR 15) Repaglinide Insulin

Stop the unsafe drugs, monitor and treat if needed.

4 full time OP clinics Antenatal Ward referrals

Inappropriate referrals (sort it yourselves) Dose adjustment of insulin for hyper /

hypoglycaemia Dose adjustment of oral medication

If you ask for our help, take it.

Diabetes Nurses / SpRs / Consultants

www.diabetes.nhs.uk

www.diabetes.nhs.uk/safe_use_of_insulin

www.diabetesbible.com

www.mims.co.uk