Diabetes mellitus Starting a newly diagnosed person with Type 1 diabetes on insulin and adjusting insulin for established insulin treatment

Principle: Each person must be individually assessed. Indication for commencing insulin therapy will be based on one or a combination of symptoms and biochemistry results.

Clinical condition or situation to which this protocol applies: This group protocol applies to the commencement of treatment of sub-cutaneous insulin in patient diagnosed with Type 1 diabetes mellitus.

• Diabetes specialist nurses working within the Northumbria Diabetes Team will use this group protocol prescribe insulin following the diagnosis of Type 1 diabetes. 
• Patients will be seen as soon as possible by the Specialist Diabetes Team, following referral from a General Practitioner.
• The patient may not be seen by a hospital doctor prior to commencing insulin. Insulin will then be prescribed following discussion with the relevant physician.

Diagnosis

Patient Symptoms and criteria for primary consideration: 

• Laboratory blood glucose result of 11.1 mmol or above. 
• Moderate or more ketonuria (Ketostix 3.9 mmol/L or above). 
• An abrupt onset with symptoms of one month or less at time of presentation. 
• Severe symptoms of polyuria, polydipsia, recurrent infections, balanitis, thrush. 
• Marked rapid weight loss over a few weeks rather than months. 
• Family history of Type 1 Diabetes. 
• Patients found to have an abnormal blood glucose level during pregnancy - use pregnancy protocol.

Criteria for secondary consideration: 

• Age less than 40 years. 
• Patients developing Type 1 Diabetes are generally under forty years of age, although all patients over 40 year with symptoms for primary consideration should be discussed with senior medical staff and the need for insuli treatment considered. 
• NB: High BMI does not contraindicate need for insulin. NB: Blood glucose alone is not a sufficient indicator

Insulin therapy can be commenced at a number of sites including a patient's home, (this may be a nursing o residential care premises) on a hospital ward, within the hospital diabetes clinic or in primary care.

Starting insulin therapy in the patients home - points to consider 

• Safe if the person is not vomiting, not severely acidotic and has no medical condition requiring admission. 
• If the patient is vomiting and unwell admission to hospital will be necessary. 
• Experienced nursing and medical support is available for supervision of the patient, either at the hospital o primary care. 
• Patients who commence insulin on a hospital ward will have had the initial diagnosis confirmed by the relevant physician. The first dose of sub-cutaneous insulin will he administered on the ward. 
• NB: Consider psychological or social problems, which may affect coping in the community

Exclusion

• Patients diagnosed with Type 2 Diabetes will initially commence treatment of diet, or diet and hypoglycaemic agent (see protocol for Type 2 Diabetes). 
• Children and young adults up to the age of 19 years. Supervision and commencement of insu]in therapy is by paediatric I young adult team using appropriate protocol. 
• Patients with concurrent medical problems requiting hospital admission.

Characteristics of staff authorised to use this protocol

• Diabetes specialist nurses will be Registered General Nurses and also registered with the UKCC. Some may educated to diploma or degree level, some may have a community qualification. 
• Diabetes specialist nurses will take primary responsibility following diagnosis for supervising the adjustment insulin. 
• Practice nurses and senior community nurses who have been identified to supervise the transfer of patients insulin within primary care will also work to this protocol. This will include community nurses supervising patient self injecting insulin at home, or administering insulin to patients who cannot self-administer, using dc adjustment guidelines. 
• Senior Dieticians trained to Diabetes Advisor level may also adjust insulin.

Staff training

• All nurses including community and practice nurses and dieticians using this protocol should have special diabetes training. This is normally provided within the district diabetes service as in-service training. Regular updates should be a part of multi-disciplinary in-service training programme. Accredited courses available: EN 928, UNN Diabetes in the Community.

Principles of Insulin therapy

• Insulin must be present throughout a 24hr period. A basal level is required to maintain cellular health with increased amounts to utilise food. 
• A continuous supply of insulin is particularly important after ketoacidosis, via intermediate acting insulin given twice a day or by sufficient boluses of short acting insulin, in combination with intermediate acting insulin.

Insulin prescribing

All medicines included in this protocol are insulin and have "Pharmacy" status. The following insulins will be used: 

• Commencement is usually on Isophane Insulin (or Isophane Insulatard for pens) at a small dose given subcutaneous injection. 
• Insulin 5u bd (6u. for a pen which delivers in multiples of 2u.) if the random laboratory blood glucose level below 15mmol/L. 
• Insulin 10 units bd if the blood glucose is 15mmol/L or above. 
• Insulin is increased by 2units bd until blood glucose readings are under 10 mmol/L. Insulin can be increased by 4 units bd if blood glucose level remains above l7mmol after 48hrs of insulin therapy.

If daily insulin requirements increase to 20u in a single dose of intermediate acting insulin e.g. Insulatard, soluble insulin is introduced to the regime as follows:

• Introduction of a pre-mixed Biphasic insulin (Human Mixtard) Start with Mixtard 30.
• A mixture of soluble insulin and insulin zinc suspension (Human Actrapid and Human Monotard). This will not be initially prescribed for newly diagnosed patients but is here for completeness.

Usually 2/3 of the total daily dose is required at the morning injection and 1/3 in the evening. The dose ratio should commence with 1/3 soluble 2/3 zinc suspension. 

Or a Basal Bolus regime to allow greater flexibility of meal timing, meal sizes and content. This is a combination of pre prandial soluble (Actrapid )insulin, given with a background of medium / long acting insulin taken bedtime using Insulatard or Ultratard insulin. (Background insulin is between 40% - 50% of total daily requirements, this dose is adjusted according to the fasting glucose result).

Supervision is maintained until blood glucose levels are in the target range. The aim is to reduce all blood glucose results below 10mmol with the first two weeks of insulin therapy. The long-term range is between 4 and 8mmol for young fit patients and between 4 and 10 mmol for patients over 70 years, or for those with special medical needs.

Increase each insulin by 2-4 units at each injection up to a maximum of 10 units increase per day. Insulin is adjusted according to blood glucose levels, dietary needs and symptoms.

When insulin is prescribed twice daily, this is given before breakfast, and before the evening meal. The two injections should be not less than 7 hours apart. The aim should be to accommodate the patients preferred routine as much possible, and allow for some flexibility with the timing of meals.

Consider Biphasic insulin immediately for young fit people with good understanding. Biphasic insulin initially prescribed for newly diagnosed children, usually human Mixtard 30 (see paediatric protocol).

A pen injection device is considered for patients who: 

• Would gain independence for self injection At the patients request for ease of administration 
• Have a physical problem with sight or dexterity which would inhibit correct drawing up of insulin into a syringe

Dietary advice

• Emergency dietary advice is to be given immediately. 
• Further dietary assessment in DRC or home assessment by dietitian to be arranged.

Patient Education

• Systematic ongoing diabetes education is commenced, this will include teaching adjusting the insulin dose according to the blood glucose levels, dietary intake and planned activity, to enable future self management. 
• Blood glucose monitoring is carried out before each meal and measured by either BM 1-44 test strips for visual monitoring, or a blood glucose meter with the appropriate test strips. 
• Appendix 1: Education check list.

Criteria for a patient to make contact

If blood glucose falls to 6mmol or below during the first three weeks of treatment (provided this has not already in identified) If blood glucose levels rise to 17mmol or above on two consecutive tests (providing previous results were 10mmol or below) 

Contact is essential if blood glucose rises and urine ketone levels increase.

Adverse drug reactions

All suspected adverse reactions to insulin therapy should be reported to a doctor within 3 working days unless the patient is systemically effected when immediate medical attention is required.

Commencement and any change in treatment including a change in insulin type should be documented on the home visiting record. This may also be used for audit purposes.

Hypoglycaemia: this is an anticipated side effect of insulin therapy. Patients receive education, which enables them to learn how to recognise their symptoms, and self-administer appropriate treatment. Family and carers will also receive education to enable them to deal with unrecognised hypoglycaemia.

Supplementary prescribing

Actrapid insulin and Ketostix is provided for illness management and Glucagen injection kit for severe hypoglycaemia, with appropriate training to patient and carer, BD safeclip for safe needle disposal.

References

• The review of prescribing, supply and administration of medicines: A report on the Supply and Administration I
• Medicines under a group Protocol. Department of Health April 1998. The supply and administration of medicines under group protocol arrangements, Royal College of Nursing 1998.

Source: Northumbria NHS Health Care Trust diabetes protocol

• Brad Cheek: last updated Dec 2006
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