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Unwell Insulin initiation

Insulin initiation whilst unwell should generally be considered to be a temporary strategy that will be reversed once the illness has resolved.  Evidence suggests that those patients initiated onto long-term insulin whilst unwell do not receive or possibly retain the detailed levels of information usually given for planned long-term insulin initiation and as a result are less effective in their self-management.

Strategy for short-term illness-related insulin use is thus simpler and more ‘didactic’ than usual insulin initiation, reflecting the different physiological circumstances and priorities

Usual strategies

Eating normally

A twice daily pre-mixed insulin (mixtard 30 / humulin M3) from a disposable pen device starting at 8-10 units each injection (same am and pm doses), blood glucose monitoring pre-meal and pre-bed  to guide future up-titration (generally undertaken as 10% TDD -Total daily insulin dose- [initially 2 units] for each injection each 24hours that the average blood glucose remains greater than 10mmol/L, reducing by 50% for each day the average blood glucose falls below 6mmol/L

Not eating well

A twice daily basal NPH insulin (insulatard / humulin I) initiated, monitored and titrated as for pre-mixed insulin

 

Although in some frail individuals who will need District Nurse support to administer insulin, a daily (usually am) dose of long-acting insulin analogue is appropriate.  Our present practice does not routinely recommend this during illness as the titration regimen is potentially rather slower because of the prolonged half-life and thus ‘steady-state’ attainment.