6.3 Diabetes mellitus and hypoglycaemia

6.3 Diabetes mellitus and hypoglycaemia

See NICE clinical guidance NG18- Diabetes (type 1 and 2) in children and young people: diagnosis and management

See NICE clinical guidance NG17 – Diabetes (types 1 and 2) – long acting insulin analogues

6.3.1 Diabetes mellitus

Biguanides

Metformin (TLS Green)

Insulins

The Patient Safety First Standards for insulin prescriptions include that:

1. The date of prescription is clearly written
2. The prescriber's signature and contact details are included
3. Both the word ‘insulin' and the brand name are written in full
4. The word ‘units' is written in full with no abbreviations
5. The form of dosage, ie cartridge, pen or vial, is clearly written

Biosimilars are not interchangeable and should only be switched during the patient's clinical review as a planned process

Short-acting Insulins

Actrapid^® Insulin (TLS Green)

• Only available as 10mL vial

Insulin Aspart:

NovoRapid^® (TLS Blue)

• 10mL vial, 3mL cartridges and prefilled device FlexPen^®
• PumpCart for use with insulin pump

Trurapi^® (TLS green) 

• Trurapi^® is a biosimilar of Novorapid^®
• Biosimilars are not interchangeable and should only be switched during the patient's clinical review as a planned process

Insulin Fiasp (TLS Amber Specialist Recommended)

• For type 1 diabetic patients with or without insulin pumps where postprandial hyperglycaemia is a particular problem

Insulin Lispro:

Humalog^® (TLS Green)

• 10mL vial, 3mL cartridges and prefilled pen KwikPen^®

Isophane Insulin:

Insulatard^® (TLS Green)

• 10mL vial, 3mL cartridges and prefilled device InnoLet^®
• Innolet device to be discontinued - expected supply end date May 2024

Insulin Glargine:

Lantus^® (TLS Green)

• 10mL vial, 3mL cartridges and prefilled device Solostar^®

Insulin Detemir:

Levemir^® (TLS Green)

• 10mL vial, 3mL cartridges and prefilled device FlexPen^®

 Insulin Degludec:

Tresiba^® (TLS Amber 3 months)

• Shared care protocol
• 3mL cartridges and prefilled device FlexTouch^®
• See MHRA Drug Safety Update
• 200units per mL: Only for obese patients with insulin resistant Type 1 diabetic patients 

Biphasic Insulins

Biphasic Insulin Aspart:

Novomix^® 30 Insulin (TLS Green)

• 3mL cartridges and prefilled device Flexpen^®

Humalog^® Mix 25 (TLS Green)

• 10mL vial, 3mL cartridges and prefilled device Kwikpen^®

Humalog^® Mix 50 (TLS Green)

• 10mL vial, 3mL cartridges and prefilled device Kwikpen^®

Biphasic Insulin Isophane Insulin:

Humulin M3^® Insulin (TLS Green)

• 10mL vial, 3mL cartridges and prefilled device Kwikpen^®

Other:

Humulin^® R Insulin 500 units/mL (unlicensed) (TLS Red)

• 20mL vial
• Prefilled pens

Sulfonylureas

Gliclazide (TLS Green)

• Not including gliclazide modified-release preparation

Alternative:

Tolbutamide (TLS Blue)

• Tolbutamide is shorter acting than gliclazide and is therefore preferable in patients at particular risk of hypoglycaemia

Glucagon-like Peptide-1 Receptor Agonists

A NPSA alert has been issued (click here to view) advising that there are very limited, intermittent supplies of all GLP-1 RAs licensed in the management of T2DM. Supply is not expected to return to normal until at least the 2024. 

For support in managing patients affected by the supply issue please refer back to secondary care for review. Please refer to the actions to be completed in the NPSA alert.

Liraglutide (TLS Red)

• For the treatment of type 2 diabetes mellitus
• According to NICE guidance NG18
• Existing patients only.  No new patients should be started on liraglutide until current supply issues resolved.

6.3.2 Diabetes mellitus, diagnosis and monitoring

In primary care the appropriate strips for the patient's meter should be used. 
(blood glucose)

Blood monitoring - Secondary Care

The Type 1 diabetes test strip guidelines recommend that children should have the test strips advised by secondary care

StatStrip^® Glucose (TLS Green)

StatStrip^® Ket-Test (TLS Green)

CareSens Pro^® Glucose testing strips (TLS Green)

Contour Next^® strips (TLS Green)

• For insulin pumps

Urinalysis

Diastix^® (TLS Green)

Ketostix^® (TLS Green)

Ketone strips

Ketosens^® (TLS Green)

Pen Needles

BD Viva^® 4mm/32G (TLS Green)

Paediatric patients requiring safety pen needles are currently excluded from the safety needle recommendation made in the pen needle guidance because of administration and training issues in this patient group. These patients should be continued on the safety pen needle as recommended by the specialist.

BD Autoshield^® safety needles (TLS Green)

• Paediatric team safety needle of choice

The 'Clinical Pathway for use of diabetes technologies in all patients with type 1 diabetes' is available from the  Paediatric Local guideline page here

6.3.3 Hypoglycaemia

Glucogel^® (TLS Green)

• Glucogel^® should be reserved for patients unable to swallow fluids and is designed to be rubbed onto the patient's gums
• For the Glucose Tolerance Test, Lucozade^® Energy Original is the only suitable formulation as the only sugar that it contains is glucose

Alternative:

Glucagon - acute insulin-induced hypoglycaemia (TLS Blue)

• If glucagon is not effective within 10 minutes, intravenous glucose should be given

Glucose (parenteral) (TLS Red)

• According to local guidelines
• In acute insulin-induced hypoglycaemia, intravenous glucose should be used for patients where glucagon has not been effective after 10 minutes
• A continuous infusion is used in the management of neonates

6.3.4 Hypoglycaemia, chronic

Diazoxide (TLS Red)

• According to local guidelines
• requires a diuretic to be prescribed alongside

6.3.5 Hyperinsulinaemia

Treatment of neonatal hyperinsulinaemia

Octreotide (TLS Red)

• As per NHS England Commissioning Policy