BNF for Children 2011-2012

354 6.1.1 Insulins BNFC 2011–20126 Endocrine systemIsophane insulin is a suspension of insulin with protamine;it is of particular value for initiation of twice-dailyinsulin regimens. Isophane can be mixed with solubleinsulin before injection but ready-mixed preparationsmay be more appropriate (biphasic isophane insulin,biphasic insulin aspart, or biphasic insulin lispro).Insulin zinc suspension (30% amorphous, 70% crystalline)has a more prolonged duration of action.Protamine zinc insulin is usually given once daily withshort-acting (soluble) insulin. It has the drawback ofbinding with the soluble insulin when mixed in thesame syringe and is now rarely used.Insulin detemir and insulin glargine are long-actinghuman insulin analogues with a prolonged duration ofaction; insulin detemir is given once or twice daily andinsulin glargine is given once daily. These long-actinginsulins are ideal for once or twice daily dosing in amultiple injection regimen in combination with a shortactinginsulin before meals.NICE (May 2009) has recommended that, if insulin isrequired in patients with type 2 diabetes, insulin detemiror insulin glargine may be considered for those:. who require assistance with injecting insulin or. whose lifestyle is significantly restricted by recurrentsymptomatic hypoglycaemia or. who would otherwise need twice-daily basal insulininjections in combination with oral antidiabeticdrugs or. who cannot use the device needed to inject isophaneinsulin.INSULIN DETEMIR(Recombinant human insulin analogue—longacting)Cautions section 6.1.1; interactions: Appendix 1(antidiabetics)Hepatic impairment section 6.1.1Renal impairment section 6.1.1Pregnancy section 6.1.1Breast-feeding section 6.1.1Side-effects see under Insulin (section 6.1.1.1)Licensed use not licensed for use in children under 6yearsIndication and doseDiabetes mellitus. By subcutaneous injectionChild over 6 years according to requirementsLevemir c (Novo Nordisk) AInjection, insulin detemir (recombinant human insulinanalogue) 100 units/mL, net price 5 3-mL cartridge(for NovoPen c devices) = £42.00; 5 3-mL FlexPen cprefilled disposable injection device (range 1–60 units,allowing 1-unit dosage adjustment) = £42.00; 5 3-mL Levemir InnoLet c prefilled disposable injectiondevices (range 1–50 units, allowing 1-unit dosageadjustment) = £44.85Counselling Show container to child or carer and confirmthe expected version is dispensedINSULIN GLARGINE(Recombinant human insulin analogue—longacting)Cautions section 6.1.1; interactions: Appendix 1(antidiabetics)Hepatic impairment section 6.1.1Renal impairment section 6.1.1Pregnancy section 6.1.1Breast-feeding section 6.1.1Side-effects see under Insulin (section 6.1.1.1)Licensed use not licensed for use in children under 6yearsIndication and doseDiabetes mellitus. By subcutaneous injectionAccording to requirementsLantus c (Sanofi-Aventis) AInjection, insulin glargine (recombinant human insulinanalogue) 100 units/mL, net price 10-mL vial =£26.00; 5 3-mL cartridge (for ClikSTAR c ,OptiPen c Pro 1, and Autopen c 24) = £39.00; 5 3-mL OptiClik c cartridge (for OptiClik c Pen) = £40.36;5 3-mL Lantus c OptiSet c prefilled disposableinjection devices (range 2–40 units, allowing 2-unitdosage adjustment) = £39.00; 5 3-mL Lantus cSoloStar c prefilled disposable injection devices(range 1–80 units, allowing 1-unit dosage adjustment)= £40.36Note The Scottish Medicines Consortium (p. 3) has advised(October 2002) that insulin glargine is accepted for restricteduse within NHS Scotland for the treatment of type 1 diabetes:. in those who are at risk of or experience unacceptablefrequency or severity of nocturnal hypoglycaemia onattempting to achieve better hypoglycaemic control duringtreatment with other insulins. as a once daily insulin therapy for patients who require acarer to administer their insulin.It is not recommended for routine use in patients with type 2diabetes unless they suffer from recurrent episodes ofhypoglycaemia or require assistance with their insulininjections.Counselling Show container to child or carer and confirmthe expected version is dispensedINSULIN ZINC SUSPENSION(Insulin Zinc Suspension (Mixed)—long acting)A sterile neutral suspension of bovine insulin or of humaninsulin in the form of a complex obtained by the addition of asuitable zinc salt; consists of rhombohedral crystals (10–40 microns) and of particles of no uniform shape (not exceeding2 microns)Cautions section 6.1.1; interactions: Appendix 1(antidiabetics)Hepatic impairment section 6.1.1Renal impairment section 6.1.1Pregnancy section 6.1.1Breast-feeding section 6.1.1Side-effects see under Insulin (section 6.1.1.1)Indication and doseDiabetes mellitus. By subcutaneous injectionAccording to requirements