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1 2 3 4 5 6 7 8Why a toolkit?The right time The right insulin Mythsand barriersInsulin management:key factsCommissioning forpeople with Type 2diabetesMedicinesoptimisationteamsCommunitypharmacy9AcknowledgementsInsulin regimes – using the Right Insulin2 Biphasic insulinInsulin ActivityBiphasic insulin (or pre-mixed insulin) containsa mixture of two components, generally a rapidor short acting insulin along with a longer actingcomponent. The different types of pre-mixedinsulin are detailed below.Pre-mixed isophane Insulin – Humulin® M3 35 , Insuman®Comb 15 35 , Insuman® Comb 25 35 , Insuman® Comb 50 35LongactingShortactingOnset: 30 minsPeak: 2-8 hrsDuration: up to 24hrs0 2 4 6 8 10 12 14 16 185 20 22 24Hours of actionThese contain mixtures of short acting andisophane insulin. These are usually injected upto 30 minutes before a meal 63 .Insulin ActivityPre-mixed Analogues – NovoMix® 30 64 , Humalog®RapidOnset: 5-15 hrsMix25 65 , Humalog® Mix50 65actingPeak: 1-4 hrsDuration: 24 hrsLongacting0 2 4 6 8 10 12 14 16 185 20 22 24Hours of actionPre-mixed analogues are a mixture of rapidactinginsulin analogue (insulin aspart orinsulin lispro) and the same rapid-acting insulinanalogue attached to protamine. Protamineprolongs its absorption so that it transformsinto an intermediate-acting insulin with NPH-likepharmacokinetics. This insulin can be injectedimmediately before or right after a meal 64,65 .When might more complex regimes bemore appropriate than basal regime?There are several indications when to considerinitiating a more complex insulin regimen suchas a biphasic preparation or basal-bolus regime:• Current HbA 1cis >2% higher than the targetHbA 1c• If the fasting glucose levels have improvedhowever HbA 1cremains significantly elevateddue to post-prandial hyperglycaemia 20,21,50• Hypoglycaemia is a concern 20,50• Patients preference for greater flexibility inan insulin regime i.e due to work, exercise,erratic lifestyle• In those with both high fasting and mealtimeblood glucose readings 46,50• In patients who maintain a fairly constantroutine of meals (timing and content ofcarbohydrate) and lifestyle 38,46Back to contentsReferencesRight Insulin, Right Time, Right Dose 39