1. BMJ LEARNING VIDEO TRANSCRIPT
Quick tips: initiating insulin in type 2 diabetes in primary care – video 1
START AUDIO
(Music)
Martin Hadley-Brown: We normally consider starting insulin for patients with
type II diabetes when we’re failing to obtain their target HbA1c
control with at least two oral hypoglycaemic agents. There are
occasions when a patient is particularly symptomatic with high
sugars when we might consider starting insulin earlier, and
there are a few specific scenarios when insulin may be started,
such as after heart attacks.
In general, I think we wait too long before we start insulin
therapy in type II diabetes. The SOLVE study, for example,
showed that the average HbA1c of someone starting insulin
was 9.8%. That’s really much too high, asking for
complications.
I think it’s probably a combination of clinician reluctance, a lack
of confidence on the part of doctors and nurses to broach the
subject, as well as the technical matters of it, as well as patient
reluctance. That patient reluctance, I think, may be centred
around the old-fashioned injections of insulin that they might
have seen their grandparents doing, using a big syringe, a
rather large needle, whereas nowadays injecting insulin truly is
a very straightforward process. I think people need to be much,
much less scared of it, so one of my messages would be: use
insulin more readily and earlier.
2. Let’s start with the benefits of insulin therapy. It’s the most
effective drug for controlling glucose levels that we have. It’s
the longest proven and it comes out very, very well in safety
studies, so it works.
In terms of flexibility, we have different types of insulin, so
we’ve got a very flexible treatment there, as well, in terms of
frequency of dosing and amount. In terms of the downsides of
insulin, obviously there is the complexity of introducing it to
patients and to clinicians, getting over the education hurdles of
knowing how to use this therapy safely.
There are probably some worries people have about insulin,
thinking that “This must be only being used because my
disease has got much worse.” I think we have a big job in
reassuring patients that insulin is a good, safe, effective
therapy, at the right time, for the right patient.
There are obvious dangers: hypoglycaemia if the dosage is
wrong or people’s activities change dramatically and if they’re
not aware of how to change their food intake or their insulin
dose. Unfortunately, insulin is amongst the two drugs which
cause the most admissions to accident and emergency
departments because of problems. Anticoagulants are the
other one, where, of course, patient and doctor monitoring is
important. Insulin, I’m afraid, is along there.
That’s anything down to prescribing errors, where we
encourage people to be very, very clear in writing the doses
they mean in terms of, say, ‘10 units’ rather than ‘10 U’, making
sure patients know exactly what they should be doing with the
insulin, and the exceptions when they should be altering
dosage or seeking further advice.
For example, whereas you might not need to change the dose
of a tablet when you’ve got flu, for insulin you probably do, and
2
3. you need to know how to do that. Another issue is that
unfortunately people using insulin, particularly in large doses,
do tend to gain weight because insulin, of course, is a growth
factor.
I think the first thing we need to understand before someone’s
starting insulin therapy is the aims and objectives of the
therapy. Those need to be agreed with the patient: why they’re
starting insulin, what the intended objectives are – for example,
targets for glucose control, maybe how much better we’re
hoping they’re going to feel. So, I think it’s very important that
objectives are out in the open and shared so that the patient
knows what they can expect with use of insulin, and roughly
how long that’s going to take.
Part of that discussion also has to be around any restrictions
they’re going to encounter by using insulin. I’m thinking
particularly here, perhaps, of restrictions on driving, particularly
with Class 2 licences, where the DVLA guidelines are very
strong – not so much on the use of insulin but on
hypoglycaemia.
People also need to know about the implications of using
insulin on travel, for example, carrying needles through
customs control, about the necessity to be aware of dose
alterations during exercise and illness – sometimes what we
call ‘sick-day rules’.
All of this is really part of a comprehensive education package
that must go before insulin is initiated, whether it’s done in the
practice or in specialist care. It’s absolutely essential that
adequate time is given so that the patient goes away with the
appropriate knowledge and expertise – and confidence – that
they know how to handle insulin safely, how to adjust it, and
when to ask for advice.
3
4. We’re fortunate to have great flexibility in the availability of
different insulins. The downside of that, of course, can be
confusion, but to try to make things reasonably straightforward
we have the origin of the insulin. Pretty well, now you can
forget about the original porcine and bovine pork and beef
insulins; we’d never be initiating those nowadays.
There is what’s called ‘human insulin’, which is pretty well
identical to human insulin, but the pharmacological companies
have succeeded in altering the properties of those insulins, by
adding different molecules or modifying their behaviour so that
we have insulins with a range of different durations of action.
So, we can have quick-acting, short-lasting insulins; we can
have long-lasting insulins which don’t have peaks and troughs
in their activity. That’s really the difference between the
different insulins we use: short acting and longer acting.
We can demonstrate these different properties of insulins using
a straightforward graph. We’ll start off with the human or NPH
insulin, which is that long-acting insulin we’re generally going
to use first. That has a reasonably long onset; it comes on to
work within about two to four hours and continues to work for
up to sixteen hours, so we may need to use that twice a day.
The analogue long-acting insulins are little bit smoother, and
they get rid of that peak early in the NPH graph. For that
reason, it is said that they’re a little less likely to cause
hypoglycaemia during the night. That’s one of their selling
points.
Then we can come to the quick-acting insulins. The quick-
acting human insulins, it’s a slightly false name because they
don’t really kick off for the first hour or two, so, if you’re going
to use those, the patient has to take those a good 30 minutes
or so before the meal to which it relates. That’s one of the
reasons why a lot of patients prefer the analogue quick-acting
4
5. insulins, which have a very fast onset of action and fade away
after two to three hours. These insulins are really ideally placed
to deal with mealtime peaks.
The human insulins have now been supplemented by so-called
analogue insulins, and they’re really just a step further forward
in modifying the behaviour of an insulin molecule so that it
delivers a drug that has the properties we want. They are
considerably more expensive, so it’s generally recommended
that we use a long-acting – NPH, as it’s called – human insulin
as our first insulin in people with type II diabetes. That is
generally very satisfactory.
Later on, one might introduce short-acting insulins, which are
designed particularly to cover individual meals. We have also
the flexibility of mixtures of insulin. You’ll see insulins labelled,
for example, 30/70. These have a mix of a short-acting insulin
and a long-acting insulin. Usually the first figure, so the 30, is
the percentage of short-acting insulin, and the 70 the
percentage of the long-acting insulin.
We have a variety of devices available for administering
insulin, as well. We’ve moved away, fortunately, from the large
glass syringe and large glass needle feared by our
grandparents, and most people now use pen devices. These
do look like pens, and you simply dial up the appropriate dose
on the pen, fit a standard and very small needle to the end of
the pen, and administer it.
There are different makes of pen, and one thing that’s very
important is that you use the right make of pen for the insulin
you’re using. You don’t mix between brands, because there
are subtle differences. You put a cartridge from one company
in a pen of another and you won’t get the amount of insulin that
you’re expecting.
5
6. Most of the pens nowadays are fairly similar, but there are two
main types. One is the all-in-one disposable pens, where the
insulin is built into the pen, and when it’s empty you throw
away the whole device. The others are pens where you just, at
the end of the insulin, you replace the cartridge with a new
cartridge of insulin, but you carry on using the same pen.
At this point, may I just emphasise that we recommend that
every patient changes the needle after every injection of
insulin. They are disposable after just one use. Occasionally,
insulin is still given by special insulin syringes, but that’s not
something I’d really cover in the initiation of insulin; we’d be
using pens almost every time.
There are one or two devices specially modified for use for
people with poor manual dexterity, and you can find details of
them on the various websites that we’re referencing with this
film. You may also occasionally come across people using
insulin pumps. They’re not really relevant and they’re not
recommended for type II diabetes.
The companies are working hard to develop alternatives to
injecting insulin. Being a protein, unfortunately we can’t yet
take it orally, but companies are working on inhaled insulins,
on patches to apply to the skin to deliver insulin, but I think
probably for most of my career to come we’re still going to be
injecting insulin.
(Music)
END AUDIO
www.uktranscription.com
6
