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Yes

Tolerant of Metformin Pathway

1. Insulatard OD (usually nocte) with continuation of metformin and sulphonylurea. Consider Glargine if glucose levels higher at tea than in the morning.
2. Insulatard OD (usually nocte) with continuation of metformin and discontinuation of sulphonylurea. (this option is not recommended if on sulphonylurea and metformin and HbA1c > 9.0%)
3. Continue metformin and stop all other oral hypoglycaemic medications then start:
   
   
   • Novomix 30 BD with meals.
   • Humalog Mix 25 BD with meals.
   • Mixtard 30 bd with meals (may be used with Innolet device)
   • Humulin M3 bd with meals.
4. Continue metformin and start basal bolus insulin regimen Novorapid or Humalog as prandial insulin. Glargine or Levemir as basal insulin.

This would be an unusual regimen choice in someone with type 2 diabetes and disucssion with a diabetes specialist is suggested if this is being considered as the first option.

1. Patient choice of regimen and device after appropriate explanation and demonstration.
2. Need for another individual to administer insulin:
   
   
   • This may necessitate treatment with a once daily insulin regimen.
3. Signs of insulin deficiency:
   
   
   • Lean
   • Marked hyperglycaemic (HbA1c > 9%)
   • Symptoms of hyperglycaemia with weight loss
     
     These factors suggest that an individual may need more than additional basal insulin and a BD regime is probably more appropriate
4. Clinical factors necessitating rapid attainment of glycaemic control.
5. Some studies suggest lower rates of hypoglycaemia with premixed analogue insulin v.s premixed human insulin.

Intolerant of metformin pathway

1. Insulatard OD (usually nocte) with continuation of sulphonylurea.
2. Stop all other oral hypoglycaemic medications then start:
   
   
   • Novomix 30 BD with meals.
   • Humalog Mix 25 BD with meals.
   • Mixtard 30 bd wtih meals (may be used with Innolet device). Inject 20-30 minutes prior to food
   • Humulin M3 bd with meals. Inject 20-30 minutes prior to food
3. Stop all other oral hypoglycaemic medications then start basal bolus insulin regimen:
   
   
   • Novorapid or Humalog as prandial insulin.
   • Glargine or Levemir as basal insulin.

This would be an unusual regimen choice in someone with type 2 diabetes and discussion with the dabetes centre is suggested if this is being considered as the first option.

1. Patient choice of regimen and device after appropriate explanation and demonstration.
2. Need for another individual to administer insulin:
   
   
   • This may necessitate treatment with a once daily insulin regime.
3. Signs of insulin deficiency:
   
   
   • Lean
   • Marked Hyperglycaemic (HbA1c > 9%)
   • Symptoms of hyperglycaemia with weight loss
     
     These factors suggest that an individual may need more than simply topping up basal insulin and a BD regimen is probably more appropriate (or basal bolus regimen).
4. Clinical factors necessitating rapid attainment of glycaemic control.
5. Some studies suggest lower rates of hypoglycaemia with premixed analogue insulin vs. premixed human insulin

Dose titration: Glargine - Novomix 30 - Humalog Mix 25 - Mixtard 30 - Humulin M3 - Basal bolus regime.

• If 5.5 mmol/L < FCG < 9.9 mmol/L on > 2 of the previous 3 readings then increase glargine by 2 units.
• If FCG > 10mmol/L on > 2 of the previous 3 readings then increase glargine by 4 units.
• If FCG < 3.0 mmol/L then decrease glargine by 2-4 units having looked for explanations for hypogycaemia.
• If 3.1 < FCG < 3.9 on > 2 of the previous 3 readings then decrease glargine by 2 units having looked for explanations for hypoglycaemia.

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This work has been completed with the support of Lilly UK through an educational grant, which includes permission to use the basic IT structure and design of the website and the provision of Project Management training to the project team.