NICE - insulin therapy in type 1 diabetes

Insulin regimens

• multiple daily injection basal-bolus insulin regimens should be offered rather than twice-daily mixed insulin regimens, as the insulin injection regimen of choice for all adults with type 1 diabetes

Long-acting insulin

• twice-daily insulin detemir should be offered as basal insulin therapy for adults with type 1 diabetes
  
  
• consider, as an alternative basal insulin therapy for adults with type 1 diabetes:
  • an existing insulin regimen being used by the person that is achieving their agreed targets
    
    
  • once-daily insulin glargine or insulin detemir if twice-daily basal insulin injection is not acceptable to the person, or once-daily insulin glargine if insulin detemir is not tolerated

Rapid-acting insulin

• rapid-acting insulin analogues injected before meals should be offered, rather than rapid-acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
• do not advise routine use of rapid-acting insulin analogues after meals for adults with type 1 diabetes
• if an adult with type 1 diabetes has a strong preference for an alternative mealtime insulin, respect their wishes and offer the preferred insulin

Mixed insulin in type 1 diabetes

• a twice-daily human mixed insulin regimen for adults with type 1 diabetes can be considered if a multiple daily injection basal-bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is chosen
  
  
• a trial of a twice-daily analogue mixed insulin regimen can be considered if an adult using a twice-daily human mixed insulin regimen has hypoglycaemia that affects their quality of life

Optimising insulin therapy

• for adults with erratic and unpredictable blood glucose control (hyperglycaemia and hypoglycaemia at no consistent times), rather than a change in a previously optimised insulin regimen, the following should be considered:
  • injection technique
  • injection sites
  • self-monitoring skills
  • knowledge and self-management skills
  • nature of lifestyle
  • psychological and psychosocial difficulties
  • possible organic causes such as gastroparesis

Reference:

• NICE (August 2015). Type 1 diabetes in adults: diagnosis and management