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Required for all patients who have either:
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Likely or confirmed type 1 diabetes
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Previous diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic syndrome (HHS)
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Symptoms of insulin deficiency (e.g. polyuria, polydipsia, weight loss etc.)
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Significant persistent hyperglycaemia (e.g. HbA1c > 90 mmol/mol) at any stage (including at diagnosis) and/or not met glycaemic targets despite lifestyle management + maximal oral/GLP1 agonist therapy
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Start with weight-based dosing of isophane (Protaphane or Humulin NPH) or glargine (Lantus) insulin.
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0.1 units/kg daily if HbA1c < 64 mmol/mol or BMI < 18 kg/m2 or elderly or renal/liver failure
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0.2 units/kg daily if HbA1c > 64 mmol/mol and BMI > 18 kg/m2
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Glucose levels useful guide whether isophane insulin is preferable (e.g. significant fasting hyperglycaemia, hypoglycaemia late in day etc.) or glargine insulin is preferable (e.g. mild fasting hyperglycaemia, high risk of hypoglycaemia etc.).
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Basal insulin is best administered at night as major role is to counteract hepatic gluconeogenesis
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Monitor fasting glucose levels via capillary blood glucose levels or continuous glucose monitoring
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If 3 consecutive fasting glucose levels > 7 mmol/L then increase dose of basal insulin by 10% or 2 units
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Stop uptitration of basal insulin once any hypoglycaemia OR fasting glucose < 7 mmol/L OR doses reach 0.5 units/kg/day – consider adding rapid acting insulin with meals if above target HbA1c and glucose levels rising with meals
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Ensure adherence and check injection technique before increasing doses
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Clear instructions for patients on how to administer and self-titrate basal insulin
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Essential particularly if concerns over cognitive impairment (medication oversight may be required)
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Encourage development of a routine with their insulin (e.g. take with dinner or before bed every night)
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Use BD fine 4 or 5 mm needles as associated with better absorption and less pain/trauma
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Encourage rotation of injection sites
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Explain that doses may need to be reduced on the night before and on days of strenuous exercise
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Once on stable dose of basal insulin repeat HbA1c in 3 months and if above target add in bolus insulin or switch to premixed insulin according to glucose levels
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The doses of basal insulin may need to be reduced if major changes in diet (e.g. Ramadan ) or if new hypoglycaemic agents are added to the regimen
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Often > 20% dose reductions of basal insulin are required if frequent and/or severe hypoglycaemia