Insulin

Insulin regimes

The most common types of insulin regimes are:

• Basal bolus regime also known as multiple daily injections (MDI)
• Insulin pump therapy also known as continuous subcutaneous insulin infusion (CSII)

What is basal bolus or MDI therapy?

This is managing the blood glucose levels with insulin injections at least 4 times each day.

The basal bolus regime uses 2 different types of insulin. This is a combination of fast acting insulin given as a bolus with each meal or snack, as well as basal insulin, usually given once per day.

Basal insulin (long acting insulin)

Long acting insulin such as Detemir (Levemir), Tresiba (Degludec) or Glargine (Lantus) is given once daily to provide a low level of background insulin during the day and night.

This basal insulin prevents the blood glucose levels rising too high in between meals and overnight. Basal insulin has a slower onset time and lasts much longer than fast acting bolus insulin.

It lasts 20 to 24 hours and is usually given in the evening, or can be given in the morning if your child is young. Sometimes 2 doses of basal insulin may be required and will be given morning and evening. The long acting basal insulin should be given at the same time each day.

Long acting insulin does not work with food.

It provides a cushion from the more immediate signs and symptoms of diabetic ketoacidosis.

Bolus insulin (fast acting insulin)

Fast acting insulin such as NovoRapid, or fast acting insulin such as Humalog is absorbed more quickly than basal insulin and lasts for 2 to 4 hours.

They are designed to be given before food or drink containing carbohydrates to prevent the blood glucose level from rising to high.

You will be taught how much insulin to give with meals, by learning to identify and count carbohydrates.

The insulin to carbohydrate ratio is the calculation used to work out how much insulin to give at mealtime. Your diabetes team will guide you of what insulin to carbohydrate ratios to use. It is not uncommon to use different insulin to carbohydrate ratio at each meal.

Fast acting insulin works best if given 15 to 20 minutes before food.

Fast acting insulin can also be given to lower a high blood glucose level. This is called a correction dose.

More and more children and young people chose to use an insulin pump, which can give more precise glucose control but requires good baseline knowledge of diabetes and insulin. This is why all patients are started on insulin pens at diagnosis.

Types of insulins

Bolus (fast acting) insulin before meals and snacks, and also for correction doses when glucose readings are out or range.

• Aspart (Novorapid ®)
• Lispro (Humalog ®)
• Apidra (Glulisine)

In a pump, these insulins are given in tiny hourly doses and they then form the background or basal insulin.

Basal (long acting or background) insulin, 1 or 2 times per day

• Detemir (Levemir ®)
• Glargine (Lantus ®)
• Tresiba (Degludec)

Insulin pens

These hold 3mls of insulin (300 units) either in cartridges or as disposable pens. Your diabetes team will advise on the best pen as it depends on the type of insulin and whether you need 0.5 unit doses or 1.0 unit doses.

Make sure you have a spare pen and choose different colours for the rapid and long acting insulin so do not get confused.

Needles

Needles are attached to the pen and are very fine so that it reduces any discomfort to a minimum. Some people do not even feel them. For children and teenagers the 4 mm needle is recommended.

Needles should only be used once. It is important to be careful with needles and dispose of them safely in the sharps bin.

Needle (sharps) bins

You can get a sharps bin from your GP and will be replaced by the GP if you live in the Sheffield Council area. Please inform us if you do not live in Sheffield and we will advise you on your local policy.

Injection technique

Watch the nurse perform the first injection will help you to see the correct technique, the sites and also how to support your child during the procedure.

Injecting your child for the first time can be difficult both because it is a new skill but also because it can feel at odds with your usual role of protecting your child. These feelings are normal and some people find it useful to remind themselves how much better you are making your child feel by giving them the insulin that their body needs.

You will get the chance on the ward for you or your child to give injections with the nurses there to support and help you.

Please talk to one of the diabetes nurses if you would like further ideas for managing injection times, talking through and involving children in a way that is appropriate for their age, distraction techniques and using soft toys for role play are some of the strategies which can help.

Injection sites

The best place to inject is the upper area of your child’s bottom. This area has the most subcutaneous (fatty) tissue which means insulin is less likely to be injected into the muscle. Injecting into the muscle can be more painful and insulin is absorbed quickly and unpredictably.

However their tummy, upper arms and thighs are also options.

If your child is about to do some activity or exercise such as running or football, insulin injected into the legs will be absorbed very quickly.

Rotation

It is important to move around the injection area and to change sites as fatty lumps (lipos) can develop if you keep using the same area. These lumps can affect the absorption of the insulin and lead to swinging blood glucose levels and poor control.

If you are unsure ask the diabetes team to help and advise you.

Remember to regularly check injection sites for lipos as ‘Lipos can cause Hypos’

How to give insulin

Giving injections to your child may seem very worrying at first. Remember you are not alone, your diabetes nurse or a member of the ward team will be there with you at first until you feel you can manage this without their help. By using the following guidelines every time, it will soon become part of your daily routine.

Check the insulin

Check that the insulin you are to use has not passed its expiry date. Once insulin is in use, it lasts for 1 month and may be stored at room temperature. Unopened insulin must be stored in the fridge.

Make sure that you give the injection in accordance with the insulin type and the manufacturer’s instructions. Novorapid, Apidra or Lispro is to be given as a bolus and is usually injected 15 minutes before food.

Long acting or basal such as Detemir, Levemir, Tresiba or Glargine insulin is given at a set time of the day and is not related to food. Your diabetes nurse will advise you on what you should do.

Inject the insulin

Children under the age of seven will usually need someone to do the injection for them. If your child needs an injection to be administered for them by a member of staff (school or hospital) or a carer, then a safety needle (BD Autoshield 5mm) is required to prevent needlestick injuries.

At all other times use of the shortest needle possible is recommended and these currently are 4mm in length. Talk to the diabetes specialist nurse about coping and distraction techniques which may help. If you have already tried these strategies an appointment with the diabetes team psychologist may help.

• Remove the pen cap
• Attach a new pen needle
• Prime the needle with 2 units of insulin, holding the pen with needle upright
• Once a drop of insulin has been seen, the pen is ready to use. If a drop of insulin has not been seen – repeat the procedure
• Dial the number of units calculated
• Choose the injection site and hold the skin steady as this avoids injecting into the muscle.
• Inject the pen device needle at 90 degree angle, and press the button or plunger as far as it will go and count to 10. The dial will reset back to zero to indicate that the dose has been administered. It is important to count to 10 before removing the pen device to reduce insulin leakage
• After the injection, remove the pen needle from the pen using the outer cover (do not try to replace the inner needle cover) and discard carefully in the sharps container
• Replace the pen cap on the pen device

Always remove your needle after every injection to minimise the risk of accidental injection and prevent re-use of a blunted needle which will be more painful and cause more trauma to the skin.

Remember that fast acting bolus insulin should be injected into a different site to long acting basal insulin.

Your diabetes nurse will help you with the above and will be able to advise you in the first few days after diagnosis.