Study Notes: Diabetes Guideline – Insulin 1

DIABETES GUIDELINE: INSULIN

Diabetes and Insulin

Insulin is a hormone produced in the pancreas that facilitates the uptake of glucose into various cells in
the body to be used as energy. It also helps store excess glucose in the liver. When the control of insulin
fails, diabetes will result.

There are 2 main types of diabetes:

● Type 1: body fails to produce insulin due to destruction of insulin-producing cells in the pancreas
and requires the person to inject insulin.
● Type 2: person has impaired insulin secretion and insulin resistance - i.e. cells fail to use insulin
properly. Some patients may eventually require insulin injections if other oral medications fail to
control blood glucose levels adequately. Causes include: obesity, age, physical inactivity, genetic.

Types of Insulin

Laboratory-created insulin is made by recombinant DNA technology and is similar to insulin produced by
a human pancreas. The main suppliers of medical insulin in Australia include: Eli Lilly, Novo Nordisk and
Sanofi-Aventis.

There are several different types of insulin which can be categorised into their time of action. The medical
practitioner will determine which one is more suitable for certain individuals.

1. Rapid onset-fast acting insulin: NovoRapid, Humalog

2. Short-acting insulin: Actrapid, Humulin R
3. Intermediate-acting insulin: Protaphane, Humulin NPH
4. Pre-mixed Insulin: Novomix 30, Humalog Mix 25, Humalog Mix 50; Mixtard 30/70, Mixtard 50/50,
Humulin 30/70
5. Long-acting insulin: Lantus, Levemir

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Study Notes: Diabetes Guideline – Insulin 2

Table: Types of Insulin

Insulin Type Examples Onset of Peak Time Duration Notes

action (hr) of action
(hr)
Rapid onset – fast acting NovoRapid (aspart) 15min 1 4 to 5 • Clear liquid
insulin Humalog (lispro) • Inject immediately before eating

Short-acting Actrapid (neutral) 30min 2 to 3 6 to 8 • Clear liquid

Humulin R (neutral) • Inject half an hour before eating

Intermediate-acting Protaphane (isophane) 1 to 3 hr 4 to 12 16 to 24 • Cloudy liquid

Humulin NPH (isophane) • Contains protamine or zinc to delay
action
• Shake well
• Inject once or twice daily

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Study Notes: Diabetes Guideline – Insulin 3

Long-acting Lantus (glargine) 1 to 2 No peak 24 • Clear liquid

• Inject once daily
• Do not mix with other insulin in a
syringe

Levemir (detemir) 3 to 4 9 12 to 24 • Clear liquid

• Inject once or twice daily

Mixed insulin Novomix 30 15min 1 16 to 18 • Mixed insulin (rapid-acting +

Humalog Mix 25 intermediate acting)
Humalog Mix 50 • Cloudy liquid
• Inject once or twice daily

Mixtard 30/70 30min 2 to 12 16 to 24 • Mixed insulin (short-acting +

Mixtard 50/50 intermediate acting)
Humulin 30/70 • Cloudy liquid
• Inject once or twice daily

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Study Notes: Diabetes Guideline – Insulin 4

Insulin Delivery Devices

Oral, transdermal and nasal administration have been developed but are not readily available compared to subcutaneous injections.
Subcutaneous injections are the most common form of administration for insulin and are available in the form of different devices such as:
syringes, delivery devices and pumps.

1. Insulin syringes
- Single-use syringe with plunger and needle
- Use syringe to draw insulin from vials (10ml vials containing 100units/ml)
- Syringe sizes: 0.3ml (30 units), 0.5ml (50 units) or 1.0ml (100 units). Size of syringe is dependent on insulin dose (in units).
- Needle sizes (length): 8mm or 13mm

Diagram: syringe and insulin vial

Syringe Products:
Braun Omnican
BD Ultra-fine
CM Safety Syringe
Terumo

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Study Notes: Diabetes Guideline – Insulin 5

2. Insulin delivery devices

a) Cartridges/Penfills: 3ml cartridges containing 100units/ml insulin fits into a durable insulin pen device. A new cartridge is inserted
once it is finished.
Table: Insulin pen devices and cartridges

Insulin pen devices Insulin cartridge/penfill

NovoPen® NovoRapid®
Actrapid®
Protaphane®
NovoMix®
Mixtard®
Levemir®

*Recommended pen needles: NovoFine

AutoPen® Lantus®

*Recommended pen needles: Unifine Pentips

HumaPen® Luxura Humalog®
Humulin®

*Recommended pen needles: BD Ultra-Fine

*Note: although most pen needles are interchangeable and used for different devices, the above recommendations are based upon the
information provided by the pen/device manufacturer.

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Study Notes: Diabetes Guideline – Insulin 6

b) Pre-filled devices: disposable devices prefilled with insulin.

Table: Types of Pre-filled insulin devices

FlexPen® NovoLet®

*Recommended pen needles: NovoFine

*Recommended pen needles: NovoFine

InnoLet® KwikPen®

*Recommended pen needles: NovoFine *Recommended pen needles: BD Ultra-Fine

Solostar®

*Recommended pen needles: BD Micro-Fine

*Note: although most pen needles are interchangeable and used for different devices, the above
recommendations are based upon the information provided by the pen/device manufacturer.

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Study Notes: Diabetes Guideline – Insulin 7

For all types of insulin delivery devices, a pen needle is required:

• Needle is screwed onto the device and used once per injection.
• Needle sizes (length): 5mm, 6mm, 8mm or 12mm
• Needle sizes (thickness/gauge): 28G, 29G, 30G, 31G (The higher the number, the
finer the needle is)

Pen needles:
Braun Omnican Mini Pen Needles 30g x 8mm
BD Microfine + Pen Needles
Novofine Pen Needles
Penfine Universal Click Pen Needle
Unifine Pentips

Choosing needles:
• Longer needles are useful for obese adults
• Deeper penetration places medication deeper than pain nerve endings
• May inject at 45 degree angle with longer needles (90 degree angle for shorter needles)
• Shorter needles are useful for children and thin adults.

Table: Insulin Forms

Insulin (brand) Available forms on market

NovoRapid Vial, Penfill, FlexPen

Actrapid Vial, Penfill

Protaphane Vial, Penfill, InnoLet, NovoLet

NovoMix Penfill, FlexPen

Mixtard 30/70 Penfill, InnoLet

Mixtard 50/50 Penfill

Humulin R Vial, Cartridge

Humulin NPH Vial, Cartridge
Humulin 30/70 Vial, Cartridge

Humalog Vial, Cartridge, KwikPen

Humalog Mix25 & Mix50 Cartridge, KwikPen

Lantus Vial, Cartridge, Solostar

Levemir Penfill, FlexPen

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Study Notes: Diabetes Guideline – Insulin 8

3. Insulin pump
An insulin pump is a small programmable device that contains insulin. It is worn outside the body – in a pouch or clipped onto a belt. It is
programmed to deliver insulin into the body through a thin plastic tube (infusion) via a fine needle/cannula that is inserted below the skin
(usually on the abdomen area) where it stays in place for two to three days. It is an alternative to multiple daily injections of insulin by
syringe or pen and is only used for rapid or short-acting insulin.

It delivers fast-acting insulin in two ways:

a) A bolus dose is pumped to provide an extra boost of insulin to counteract food being eaten.
b) A basal dose is pumped continuously based on an adjustable basal rate to deliver insulin needed between meals and at night.

Advantages
• Convenient and discreet form of insulin administration
• Accurate record of insulin usage that can be computer-
analysed
• Patient compliance
• Freedom from a structured meal and exercise regimen
• Better control of blood sugar levels
Disadvantages
• Costly: insulin pumps, cartridges and infusion sets are more
expensive than syringes
• Pump needs to be worn so may limit certain activities that may
damage the pump such as swimming, extreme sports etc
• Wearing the pump may be uncomfortable
• Possibility of insulin pump malfunction
• Scar tissue building due to the inserted cannula
• Allergic reactions or skin irritation from adhesive of infusion set
• Larger supply of insulin may be required to use the pump to
cater for wastage involved with refilling reservoir or changing
infusion sets.

In Australia, it is mainly marketed for people with Type 1 diabetes. Subsidies exist through Diabetes
Australia and Commonwealth Department of Health and Aging but individuals must meet and be
assessed against a set of criteria first. The assessment must be completed by an endocrinologist,
credential diabetes education or specialist physician.

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Study Notes: Diabetes Guideline – Insulin 9

How is insulin injected?

Step-by-step

1. Choose an area to inject the alcohol.

2. Clean area with alcohol swab.
3. Pinch skin into a fold and hold. A fatty area is less painful and helps absorb insulin better.
4. Insert needle quickly and accurately at 45-90 degree angle.
5. Insert needle deep enough and inject insulin by pushing the top of the syringe all the way down or
the button of a pen.
6. Hold in that position for 5 seconds and then remove needle by pulling it straight out for minimal
pain.
7. Pull out needle and dispose in a sharps container.

Tips:

• Most common and best area to inject insulin is the abdomen area. It absorbs insulin the best.
Buttocks, thighs, upper arms can also be used.
• Avoid injecting into a muscle as it is painful and will cause insulin to be absorbed into the body
too quickly.
• Avoid injecting insulin directly into a bloodstream.
• Rotate sites of injection to prevent skin irritation.
• Change needle with each injection.
• Gently roll vials back and forth with the palm of your hands to mix the insulin. Do not shake as it
can create bubbles.
• For pen insulin, roll back and forth with palms as well as shake the pen to mix the insulin.

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Study Notes: Diabetes Guideline – Insulin 10

Counselling Points: Diabetes & Insulin

Hypoglycaemia
• Watch out for signs and symptoms of hypoglycaemia (low blood sugar levels): lethargy,
confusion, sweating, twitching, trembling, dizziness, headache, light headedness, lack of
concentration, pale, loss of consciousness
• Causes of hypoglycaemia: delaying/missing a meal, strenuous exercise, drinking alcohol,
overdose on insulin or tablets.
• In the event of hypoglycaemia, take fast-acting carbohydrates such as: glucose lollies, fruit juice,
soft drink etc. to relieve the symptoms.

Diet
• No special diet required
• Low glycaemic index (GI) foods
• Low in saturated fat
• High fibre carbohydrate foods: wholegrain breads and cereals, vegetables and fruit
• Low in salt content
• Avoid high amounts of sugars such as lollies and soft drinks
• Limit alcohol consumption.
• Artificial sweeteners preferred over sugar
• Limit serving size of your meals and make sure you eat regularly.

Exercise
• Increase general physical activity and a regular exercise program. Take it slow.
• 30min of exercise each day.
• Drink extra fluid before, during and after exercise to avoid dehydration.
• Take extra carbohydrate before and during exercise to prevent hypoglycaemia

Blood Sugar Monitoring

• Testing blood glucose levels at home will help with diabetes control.
• Frequency of testing depends on each individual, type of diabetes and medication. Usually 3-4
times daily for a person using insulin.
• Record results in a diabetes diary for self and physician records.
• When to test: before breakfast, before meals, before bed, before exercise, two hours after a meal
or when feeling unwell.

Storage
• Store unused insulin in a refrigerator. Do not freeze.
• Once opened, insulin may be kept at room temperature (less than 30 degrees Celsius) for one
month and then thrown away.
• Do not use insulin if: clear insulin has turned cloudy, expired, frozen or exposed to high
temperatures.

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Study Notes: Diabetes Guideline – Insulin 11

References / Resources

1. Diabetes Australia
2. Australian Diabetes Council
3. Australian Diabetes Educators Association (ADEA)
4. Eli Lilly
5. Sanofi-Aventis
6. Novo Nordisk
7. BD
8. Accu-Chek
9. Abbott
10. Point of Care Diagnostics (POCD)
11. Australian Medicines Handbook 2010
12. eMIMS 2010
13. myDr.com.au – Diabetes
14. Australian Pharmaceutical Formulary and Handbook 19th Edition

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Disclaimer: While every effort has been made to ensure this publication is as accurate as possible, the Medicine Box team does not
accept any responsibility for any loss which the user may suffer as a result of errors or inaccuracy of information contained in this
publication. It is also noteworthy that The Medicine Box is unaffiliated with the Pharmacy Board of Australia, the former Pharmacy
Board of NSW, the Australian Pharmacy Council or the Pharmaceutical Society of Australia. All information in this publication is
provided by past pharmacy graduates and has not been verified by the above organisations.

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