Insulin – ONCE Daily Injection


 

Lantus® [insulin glargine], Toujeo [insulin glargine], Levemir® [insulin detemir], Tresiba® [insulin degludec], Insulatard® [human insulin], Humulin® I [human insulin], Insuman® Basal [human insulin], Suliqua® [insulin glargine with lixisenatide], Xultophy® [insulin degludec with liraglutide]

 

[This monograph covers ONCE daily injections of insulin – for TWICE daily or THREE, FOUR or FIVE daily injections see separate monographs as advice is dependent on the regime used]

 

  Issues for Surgery


Hypoglycaemia if continued during nil by mouth period.

Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if discontinued.


  Advice in the Perioperative period


Insulin products are classified according to their duration of action and it is important to understand the type of insulin and the regimen the patient is on in relation to the advice to be given perioperatively. Confirm with the patient the exact name, strength, dose, frequency and preparation of insulin(s) that they are using (see Further Information).


Elective Surgery 

See figure 1 below.
When reducing insulin doses round to the nearest unit.

Figure 1 – Management of ONCE daily insulin in the Perioperative Period1

Combination Products: -

  • Suliqua® (insulin glargine + lixisenatide) – also see Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists monograph.
  • Xultophy® (insulin degludec + liraglutide) – also see Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists monograph.

Consideration should be given to prescribing the components of combination products as separate medicines perioperatively.

Emergency Surgery

The advice given above can be applied to patients presenting for emergency surgery. However, it must be remembered that these patients are high risk and are likely to require intravenous insulin infusion1.

Perioperative Considerations

Commence variable rate intravenous insulin infusion (VRIII) perioperatively where indicated, with the patient’s ONCE daily insulin continued at 80% of their usual pre-operative dose1 (see figure 1 above and Further Information).

Ensure emergency treatment of hypoglycaemia is prescribed i.e. Glucogel® and 20% dextrose. Rapid acting insulin should also be prescribed1, 2.

Post-operative Advice

Encourage an early return to normal eating and drinking (as deemed appropriate by the Surgical Team), facilitating return to the patient’s usual diabetic regimen1. The insulin dose(s) may need adjusting, as insulin requirements can change due to post-operative stress, infection or altered food intake – monitor blood glucose levels and seek advice from specialist diabetes team if necessary1, 2.


  Interaction(s) with Common Anaesthetic Agents 


Reduction in Blood-Glucose Lowering Effect

Substances that may reduce the blood-glucose-lowering effect of insulin include sympathomimetics (e.g. epinephrine / adrenaline)3, 4, 5, 6, 7, 8, 9.


  Interaction(s) with other Common Medicines used in the Perioperative Period


Enhancement of Blood-Glucose Lowering Effect

Substances that may enhance the blood-glucose lowering effect of insulin and increase susceptibility to hypoglycaemia include sulphonamide antibiotics (e.g. co-trimoxazole)3, 4, 5, 7, 8, 9, 10.

Reduction of Blood-Glucose Lowering Effect

Corticosteroids can reduce the blood-glucose-lowering effect of insulin4, 5, 6, 7, 8, 9, 10, 11. Clinically important hyperglycaemia has been seen12. Monitor blood glucose concentrations closely when corticosteroids are given to patients with diabetes12.

Octreotide may either increase or decrease insulin requirements 5, 6, 8, 9, 10.


  Further Information


Types of Insulin 

In general, ONCE daily preparations of insulin are long-acting preparations. They mimic endogenous basal insulin secretion with a prolonged duration of action (may be up to 36 hours) and are usually taken once daily, although in some cases twice daily dosing may be used depending on individual requirements2.

Safe Prescribing of Insulin

European Medicines Agency – Guidance on prevention of medication errors with high-strength insulins13

A high-strength insulin is a medicine that contains insulin at a concentration of more than the standard 100 units/ml. There are differences in the way high-strength insulin products are used compared with existing insulin formulations of standard-strength and there is therefore a risk of medication errors and accidental mix-up.

Advice for Healthcare Professionals: -

  • A syringe must NEVER be used to withdraw insulin from a pre-filled pen otherwise severe overdose can result
  • Insulin must always be prescribed in units (spelled out in full) and include the dose frequency
  • The strength of the insulin formulation should always be included in the prescription

Lantus® (insulin glargine 100 units/ml) and Toujeo® (insulin glargine 300 units/ml) are NOT bioequivalent and are NOT directly interchangeable3, 5.

VRIII

Patients with a planned short starvation period (no more than one missed meal in total) should be managed by modification of their usual diabetes medication, avoiding VRIII wherever possible. Patients expected to miss more than one meal should have VRIII1.

VRIII is the preferred method of controlling serum glucose for most patients undergoing emergency surgery1.

 

  References


  1. Joint British Diabetes Societies for Inpatient Care. Management of adults with diabetes undergoing surgery and elective procedures: improving standards (Revised March 2016). Available at: www.diabetes.org.uk [Accessed 12th March 2019]
  2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 12th March 2019]
  3. Summary of Product Characteristics – Lantus® (insulin glargine) 100 Units/ml solution for injection in Solostar pre-filled pen. SANOFI. Accessed via www.medicines.org.uk 07/08/2019 [date of revision of the text February 2019]
  4. Summary of Product Characteristics – Levemir® (insulin detemir) Innolet 100 international units/ml. Novo Nordisk Limited. Accessed via www.medicines.org.uk 07/08/2019 [date of revision of the text May 2018]
  5. Summary of Product Characteristics – Toujeo® (insulin glargine) SoloStar, solution for injection in a pre-filled pen. SANOFI. Accessed via www.medicines.org.uk 07/08/2019 [date of revision of the text June 2019]
  6. Summary of Product Characteristics – HUMULIN® I (Isophane) (human insulin) 100IU/ml suspension for injection. Eli Lilly Company Limited. Accessed via www.medicines.org.uk 08/08/2019 [date of revision of the text August 2018]
  7. Summary of Product Characteristics – Insuman® Basal (human insulin) SoloStar 100 IU/ml suspension for injection in a pre filled pen. SANOFI. Accessed via www.medicines.org.uk 08/08/2019 [date of revision of the text April 2019]
  8. Summary of Product Characteristics – Xultrophy® 100 units/ml insulin degludec + 3.6 mg/ml liraglutide solution for injection in a pre-filled pen. Novo Nordisk Limited. Accessed via www.medicines.org.uk 08/08/2019 [date of revision of the text July 2019]
  9. Summary of Product Characteristics – Tresiba® Basal (insulin degludec) 100 units/ml Pre filled (FlexTouch). Novo Nordisk Limited. Accessed via www.medicines.org.uk 08/08/2019 [date of revision of the text November 2018]
  10. Summary of Product Characteristics – Insulatard® (human insulin) Penfill 100 international units/ml. Novo Nordisk Limited. Accessed via www.medicines.org.uk 07/08/2019 [date of revision of the text May 2018]
  11. Insulin. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 30th March 2019]
  12. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 7th April 2019]
  13. European Medicines Agency: Guidance on prevention of medication errors with high-strength insulins. 27 November 2015. Available at: www.ema.europa.eu [Accessed 7th August 2019)