Type 2 Diabetes: Insulin Therapy

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This tool is designed to support family physicians and primary care nurse practitioners to prescribe and manage insulin therapy for adult patients living with type 2 diabetes.

For many patients with type 2 diabetes, insulin is needed eventually. As the condition progresses, non-insulin pharmacotherapy may no longer be sufficient to maintain glycemic control over time.1

Overview of insulin therapy for type 2 diabetes2

*Functionally dependent patients have a Clinical Frailty Scale8 score of 4-5 on a 9-point scale. Patients with frailty have a Clinical Frailty Scale8 score of 6-8 on a 9-point scale.
**Some experts suggest using early, short-term (2-4 weeks) intensive insulin therapy in newly diagnosed type 2 diabetes patients with symptomatic hyperglycemia or those with high cardiovascular risk in acute care settings (e.g., acute MI, stroke, coronary artery bypass graft). This approach is associated with improvements in insulin resistance, beta cell function, quality of life and may induce remission when started within the first 2 years of diagnosis. It reflects expert opinion and is not included in current clinical practice guidelines.9,10
† And titrate dose of GLP1-RA as tolerated
†† Or fixed-ratio combination
††† If eGFR >30ml/min/1.73m2, may be used for cardiorenal benefit
Notes: DPP4i = dipeptidyl peptidase-4 inhibitor, eGFR = estimated glomerular filtration rate, GLP1-RA = glucagon-like peptide-1 receptor agonist, SGLT2i = sodium-glucose cotransporter-2 inhibitor
Bold = agents with stronger evidence

Selecting an insulin New

Different types of insulin

Basal insulin
What it is
  • Intermediate- or long-acting insulin, usually injected once daily (usually at bedtime) and used to keep blood glucose levels stable during periods of fasting (e.g., between meals, while sleeping)
When to used it
  • First-line treatment for insulin-naive patients2
  • It is a simpler treatment regimen that causes less hypoglycemia and weight gain compared to premixed insulin or prandial-only regimens2
Prandial (bolus) insulin
What it is
  • Short- or rapid-acting insulin injected at mealtime to control post-prandial (post-meal) glucose levels or for short-term correction of meal-related hyperglycemia
When to used it
  • May be added at mealtimes if glycemic control is suboptimal after 3-6 months on basal insulin (with other agents)3
  • Basal and prandial (bolus) insulin may be started together if the patient’s blood glucose level is high (>16.7 mmol/L) and metabolic decompensation is present at initial diagnosis1
Premixed insulin
What it is
  • Premixed solutions that contain two types of insulin (e.g., prandial and basal insulin)
When to used it
  • Consider for patients who cannot accommodate > 2 injections/day (e.g., those who require home care/caregiver support to administer insulin), or, patients who would have difficulty adjusting insulin doses (e.g., due to cognitive ability or visual acuity)11,12
  • This dosing option is less flexible (requires a routine mealtime to prevent hypoglycemia) and offers less ability to correct for abnormal results11

Selecting which insulin to use

  • There is not a simple reason to choose one insulin over another, within each type of insulin (basal, prandial and combination)
  • When comparing insulin options, prioritize a patient’s preference in the shared decision-making process
Common properties of insulin
  • A1C reduction
    • Effect on A1C is 0.9-1.2% or more2
    • A1C reduction depends on dose and number of injections per day3
    • Dose increases may be limited by hypoglycemia and cost2
  • Cardiorenal outcomes
    • Insulin has a neutral effect on cardiorenal outcomes (safety but no risk reduction)1,2,18-20
  • Weight
    All insulin associated with weight gain:

    • Effects on weight are dose-related
    • Basal insulin is associated with a weight gain of 1-2 kg* (over 6-12 months)2,24–26
      • Detemir and glargine 300 units/mL may lead to slightly less wei ght gain (≤1kg) than other options13,14
    • Prandial (bolus) insulin is associated with a weight gain (exact amount unknown)2
    • Premixed insulins are associated with a weight gain of 3.5-5 kg * (over 6-12 months)2,24–26
  • Harms
    • Hypoglycemia
    • Lipohypertrophy
    • Local injection site reactions (fewer with glargine vs. detemir)27
    • Allergic reactions (rare)1

Insulin specific properties

  • Onset, peak and duration of action
  • Cost
  • Coverage (ODB, NIHB)
  • Hypoglycemia risk (for basal insulin)*

See Insulin options (basal, prandial, premixed) for more information.

*Hypoglycemia risk21-23

  • Some patients benefit from choosing long-acting insulin over intermediate-acting insulin (e.g., those who do shift work, have inconsistent oral intake or those who would benefit from dosing less often)
  • For most patients, however, choosing basal insulin is not the primary factor in reducing hypoglycemia risk in a clinically meaningful way (i.e., absolute risk differences are small and the evidence is limited, making it difficult to compare basal insulins with confidence)
  • Determining other ways to reduce hypoglycemia risk is essential (see Managing hypoglycemia)
Other properties (not well studied) 13-16
  • Mortality (exception for prandial: studies have not shown a significant difference in mortality between rapid- and short-acting insulin)17
  • Quality of life

Consider affordability and environment impact of insulin New

Consider the affordability of insulin

  • Cost is an important factor for many patients.
  • Balance the consideration of cost against other factors when selecting insulin in the shared decision-making process.
  • Consider biosimilar insulin as it costs less – a biosimilar is a biologic drug that is highly similar to a biologic drug that was already authorized by Health Canada for sale.33
  • Patients’ coverage (e.g., Ontario Drug Benefit [ODB], Non-Insured Health Benefits [NIHB]) plays into cost.
    • All insulin options below have ODB and NIHB coverage unless otherwise specified.
Basal insulin
Drug cost for usual dose* (50 units/day for 100 days supply [basal alone])
Prandial (bolus) insulin
Drug cost for usual dose* (25 units/day for 100 days supply)
Basal/prandial (bolus) premixed insulin
Drug cost for usual dose* (50 units/day for 100 days supply)

* Prices reflect the cost to the customer and include markup and dispensing fee (the cost per dosage form and the 100-day cost both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box; e. g., 5x3mL pens). The cost for a usual dose assumes a 100kg patient.
** See Insulin specific properties- Prandial (bolus) insulin table for details on the limited use restrictions.

Explore patient reimbursement opportunities

Support patients to explore reimbursement opportunities for blood glucose monitoring supplies, pen needles and syringes.

Ontario Ministry of Health’s Ontario Drug Benefit (ODB) program
  • Offers all ODB recipients on insulin reimbursement for a flash glucose monitoring system (specifically, the FreeStyle Libre system), including:40
    • 1 reader/patient (otherwise costs $65)
    • 33 sensors/year/patient (otherwise costs $2,457.54/year)
  • Offers all ODB recipients coverage for a set number of blood glucose test strips annually, depending on their diabetes management approach:41
    • 3,000 test strips/year for patients on insulin
    • 400 test strips/year for patients on non-insulin pharmacotherapy with higher risk of causing hypoglycemia (e.g., glyburide, gliclazide)
    • 200 test strips/year for patients on non-insulin pharmacotherapy with lower risk of causing hypoglycemia (e.g., acarbose, metformin, canagliflozin, empagliflozin, linagliptin, saxagliptin, sitagliptin)
    • 200 test strips/year for patients on diet/lifestyle therapy only
Diabetes Canada’s Ontario Monitoring for Health Program38
  • Blood glucose test strips and lancets – up to a maximum of $920/year
  • Blood glucose meter – up to a maximum of $75/every 5 years
  • Talking blood glucose meter – up to a maximum of $300/every 5 years (note: a letter from a doctor is required to confirm visual impairment)
Ontario Ministry of Health’s Assistive Devices Program39
  • Offers patients 65+ an annual grant ($170/year) to cover the costs of needles and syringes used to inject insulin
  • Consider less expensive insulin dosage forms (e.g., vials) for patients 65+ who obtain syringe coverage

Considering the environmental impact of insulin

The environmental impact of insulin is important to some patients. Suggestions to reduce the environmental impact of insulin include:

  • Consider reusable insulin pens instead of single-use, prefilled insulin pens if available (see Insulin specific properties tables for insulin products that have reusable pens that take cartridges)30,42,43
  • Disposing of pens, syringes, needles and cartridges in a clearly-labeled, closable, puncture-resistant sharps container (can be obtained from a pharmacy) to prevent the disposal of ‘sharps’ into landfills43-45
  • If patients are using insulin exceeding amount allowed in 1 injection, consider a more concentrated insulin formulation (less volume required) and counsel the patient on appropriate dosing to avoid overdose30,34,44,46
  • Recycle the paper boxes, pamphlets and inserts packaged with insulin47

Insulin options - Basal, prandial, and premixed New

Differing properties of insulin – Basal insulin

Intermediate acting
Scroll (left-right) for details
  • 100 units/mL
    NPH (Humulin® N)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset:1-2h; Peak: 5-8h; Duration: 14-18h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 5x3mL prefilled pens: $185
    • 5x3mL cartridges: $167
    • 10mL vial: $143

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 5x3mL prefilled pens: $127
    • 5x3mL cartridges: $114
    • 10mL vial: $89
    Comments
  • 100 units/mL
    (Novolin® ge NPH)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1-2h; Peak: 5-8h; Duration: 14-18h1

    Dosage forms*28

    • 5x3mL prefilled pens
    • 10mL vial

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 5x3mL prefilled pens: $167
    • 10mL vial: $143

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 5x3mL prefilled pens: $114
    • 10mL vial: $89
    Comments
  • 100 units/mL
    †NPH pork (Hypurin® NPH)

    Not Covered by Ontario Drug Benefit28
    Not Covered by non-insured health benefits for First Nations and Inuit29

    • Onset: 1-3h; Peak: 6-12h; Duration: 24-48h1

    Dosage forms*28

    • 10mL vial

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 10mL vial: $584

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 10mL vial: $355
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

Long-acting
Scroll (left-right) for details
  • 100 units/mL
    Degludec (Tresiba®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1h; Peak: No peak; Duration: 42h1

    Dosage forms*28

    • 5x3mL prefilled pens

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 5x3mL prefilled pens: $370

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 5x3mL prefilled pens: $250
    Comments
  • 200 units/mL
    Degludec (Tresiba®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1h; Peak: No peak; Duration: 42h1

    Dosage forms*28

    • 3x3mL prefilled pens

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 3x3mL prefilled pens: $442

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 3x3mL prefilled pens: $298
    Comments
  • 100 units/mL
    Detemir (Levemir®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1.5h; Peak: No peak; Duration: 6-24h1

    Dosage forms*28

    • 5x3mL prefilled pens
    • 5x3mL penfills

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 5x3mL prefilled pens: $370
    • 5x3mL penfills: $367

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 5x3mL prefilled pens: $250
    • 5x3mL penfills: $247
    Comments
  • 100 units/mL
    Glargine (BasaglarTM)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1.5h; Peak: No peak Duration: 24h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 5x3mL prefilled pens: $234
    • 5x3mL cartridges: $234

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 5x3mL prefilled pens: $159
    • 5x3mL cartridges: $159
    Comments
  • 100 units/mL
    Glargine (Lantus®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1.5h; Peak: No peak Duration: 24h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 5x3mL prefilled pens: $310
    • 5x3mL cartridges: $310
    • 10mL vial: $209

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 5x3mL prefilled pens: $159
    • 5x3mL cartridges: $159
    • 10mL vial: $142
    Comments
  • 300 units/mL
    Glargine (Toujeo®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 1.5h; Peak: No peak; Duration: 24h1

    Dosage forms28

    • 1.5mL prefilled pens
    • 3mL prefilled pens

    Cost for usual dose (50 units/day for 100 days supply; basal alone)*30

    • 1.5mL prefilled pens: $323
    • 3mL prefilled pens: $351

    Cost for usual dose (25 units/day for 100 days supply; basal + bolus; cost is for basal component)*30

    • 1.5mL prefilled pens: $180
    • 3mL cartridges: $180
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

Differing properties of insulin – Prandial (bolus) insulin

Rapid-acting
Scroll (left-right) for details
  • 100 units/mL
    Aspart (Novorapid®)

    Covered by Ontario Drug Benefit: ODB3628
    LU 388, 389, 39035
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 9-20 min; Peak: 1-3h; Duration: 3-5h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $147
    • 5x3mL cartridges: $142
    • 10mL vial: $107
    Comments
  • 100 units/mL
    Aspart †(Fiasp®)

    Not Covered by Ontario Drug Benefit
    Not Covered by non-insured health benefits for First Nations and Inuit

    • Onset: 4h; Peak: 0.5-1.5h; Duration: 3-5h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $157
    • 5x3mL cartridges: $152
    • 10mL vial: $115
    Comments
  • 100 units/mL
    Glulisine (Apidra®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 10-15 min; Peak: 1-1.5h; Duration: 3.5-5h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $124
    • 5x3mL cartridges: $123
    • 10mL vial: $95
    Comments
  • 100 units/mL
    Lispro (Humalog®)

    Covered by Ontario Drug Benefit: ODB3628
    LU 59936
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 30-45 min; Peak: 0.75-2.5h; Duration: 3.5-4.75h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $138
    • 5x3mL cartridges: $138
    • 10mL vial: $107
    Comments
  • 100 units/mL
    Lispro (Admelog®)

    Covered by Ontario Drug Benefit: ODB3628
    Not Covered by non-insured health benefits for First Nations and Inuit

    • Onset: 30-45 min; Peak: 0.75-2.5h; Duration: 3.5-4.75h1

    Dosage forms28

    • 5x3mL prefilled pens
    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $112
    • 5x3mL cartridges: $112
    • 10mL vial: $87
    Comments
  • 200 units/mL
    Lispro (Humalog®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit: NIHB3729

    • Onset: 30-45 min; Peak: 0.75-2.5h; Duration: 3.5-4.75h1

    Dosage forms28

    • 5x3mL prefilled pens: $129

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $129
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

Short-acting
Scroll (left-right) for details
  • 100 units/mL
    Regular insulin (Humulin-R®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 30-60 min; Peak: 2-4h; Duration: 5-81

    Dosage forms*28

    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL cartridges: $115
    • 10mL vial: $89
    Comments
  • 100 units/mL
    Regular insulin (Novolinge Toronto®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 30-60 min; Peak: 2-4h Duration: 5-81

    Dosage forms*28

    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (25 units/day for 100 days supply)*30

    • 5x3mL cartridges: $112
    • 10mL vial: $88
    Comments
  • 500 units/mL
    †Regular insulin (Entuzity®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    • Onset: 3-58 min; Peak: 0.5-8h; Duration: 17-24h1

    Dosage forms*28

    • 2x3mL prefilled pens

    Cost for usual dose (25 units/day for 100 days supply)*30

      • 2x3mL prefilled pens: $120
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

Differing properties of insulin – Premixed insulin

The choice of premixed insulin will depend on the patient’s dos ing requirements for basal and prandial (bolus) insulin and which type of prandial insulin is preferred by the patient and provider

Short-acting + intermediate-acting
Scroll (left-right) for details
  • 100 units/mL
    Premixed regular-NPH (Humulin 30/70®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $176
    • 10mL vial: $151
    Comments
  • 100 units/mL
    Premixed regular-NPH (Novolin ge 30/70®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL cartridges
    • 10mL vial

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $162
    • 10mL vial: $144
    Comments
  • 100 units/mL
    Premixed regular-NPH (Novolin ge 40/60®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $163
    Comments
  • 100 units/mL
    Premixed regular-NPH (Novolin ge 50/50®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $163
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

Rapid-acting + intermediate-acting
Scroll (left-right) for details
  • 100 units/mL
    Aspart/aspart protamine suspension (Novomix® 30)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $191
    Comments
  • 100 units/mL
    Lispro/lispro protamine suspension (Humalog® Mix25)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL prefilled pens
    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $205
    • 5x3mL cartridges: $206
    Comments
  • 100 units/mL
    Lispro/lispro protamine suspension (Humalog® Mix50)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL prefilled pens
    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL prefilled pens: $201
    • 5x3mL cartridges: $203
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

GLP1-RA + insulin combinations (not premixed insulins)
Scroll (left-right) for details
  • 100 units/mL
    †Degludec/liraglutide (Xultophy®)

    Not Covered by Ontario Drug Benefit
    Not Covered by non-insured health benefits for First Nations and Inuit

    Dosage forms28

    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $1065
    Comments
  • 100 units/mL
    Glargine/ lixisenatide (Soliqua®)

    Covered by Ontario Drug Benefit: ODB3628
    Covered by non-insured health benefits for First Nations and Inuit:
    NIHB3729

    Dosage forms*28

    • 5x3mL cartridges

    Cost for usual dose (50 units/day for 100 days supply)*30

    • 5x3mL cartridges: $624
    Comments

*Prices reflect the cost to the consumer and include a markup a nd dispensing fee (the cost per dosage form and the 100-day cos t both include one dispensing fee and reflect the usual pharmacy practice of dispensing a full box or vial; e.g., 5x3mL pens). The cost for a usual dose assumes a 100 kg patient. The price for vials does not include the cost of syringes.
** This reflects the maximum amount given for 1 injection, not t he maximum amount of insulin that is required. Multiple injections may be required to achieve blood glucose targets.
† = not on Ontario drug formulary, bid = twice daily, h = hour, kg = kilogram, LU = limited use, max = maximum, μg = microgram, mg = milligram, mL = milliliter, NIHB = non-insured health benefits for First Nations and Inuit, NPH = neutral protamine Hagedorn, ODB = Ontario Drug Benefit, SC = subcutaneous

Initiating and titrating insulin New

Practical tips for discussing insulin initiation with patients

  • Start the insulin discussion early (e.g., at diagnosis and regular follow-up appointments)
  • Ensure patients understand that insulin is not a punishment or indication of treatment failure, and that many patients end up on insulin later in life
  • Consider patient values regarding the benefits/harms of adding insulin relative to the intensity of glycemic control (e.g., some patients may opt for moderate control without insulin)
  • Provide information on the benefits of insulin therapy (e.g., lower blood glucose, no gastrointestinal upset, reduces nocturnal urination secondary to hyperglycemia)
  • Understand the patient’s barriers or concerns about starting insulin
  • Consider framing starting insulin as a “trial”, with a set duration (e.g., 1 month), with a plan to discuss and adjust as needed
  • To increase their confidence before starting injection(s), give the patient time to try different insulin pens and needles
Talking points
  • “For most people living with diabetes, insulin is required at some point in their life as part of their management plan.”
  • “Since you are not feeling well now, adding insulin may help you feel better sooner.” (Offer the patient examples of their symptoms, e.g., blurred vision, fatigue, low energy. increased urination).”
  • “The insulin needle injection hurts less than a fingerprick when checking blood glucose.”
  • “Would you be open to trying insulin therapy for 1 month to see how it works for you?”

Insulin initiation checklist

Counsel patients on:
  • Insulin injection frequency and timing
  • Proper and safe insulin injection techniques, pen needle use,  insulin storage
    • Consider connecting the patient to a qualified person/program to provide this counselling (e.g., Certified Diabetes Educator, Diabetes Education Program or collaborative support [registered nurse, nurse practitioner, pharmacist, dietitian] in the office or community). See Local services for patients living with type 2 diabetesi
  • Hypoglycemia prevention and treatment (see Section E:  Managing hypoglycemia)
  • Frequency of self-monitoring of blood glucose (See Self monitoring blood glucose frequency and pattern tool)48
  • Options for blood glucose self-monitoring devices/systems (e.g., blood glucose meter, flash glucose monitoring system, continuous glucose monitoring system)
Storing insulin49, 50
  •  Unopened insulin
    • Should be stored in the fridge between 2ºC and 8ºC
    • Is good until the expiration date
  • In-use insulin
    • Should be stored at room temperature, avoiding contact  with direct sunlight
    • Is good for up to 28 days (detemir and glargine 300 units/mL  are safe at room temperature for 42 days) – counsel patient  to write the first date of use on the label
  • Discard insulin that has been frozen, kept out of the fridge  for greater than the allowed period, exposed to temperatures  greater than 30ºC or expired

Safe insulin injection techniques and pen needle use51 

  •  Injection sites and rotation (proper injection technique can significantly improve A1C and reduce erratic insulin effects and hypoglycemia)
    • Divide injection area into zones, use 1 zone per week and move clockwise, spacing out each injection within any zone by 1-2 cm
    • Avoid intramuscular injection
      • Abdomen, thighs and buttocks as the preferred self-injection areas
      • Avoid the arms
    • Avoid injecting within 2-3 cm of the umbilicus
    • Avoid injecting in altered skin (e.g., skin with surgical scars, stretch marks, lipohypertrophy, tattoos, moles, skin conditions)
  • Pen needles
    • Insulin should be brought to room temperature before injecting
    • Inject pen needles at a 90˚ angle
    • Avoid reusing pen needles or syringes
    • Use pen needle sized 4-6 mm for all patients regardless of body mass index (4 mm pen needles provide the equivalent A1C control as both as 8 mm and 12 mm pen needles in people with obesity who are taking large doses of insulin)52
  • See FIT technique plusii for a series of patient educational tools on best practice injection technique and pen needle use

Injection site rotation

Pen needle wear after use

Insulin initiation and titration process – Basal insulin

Insulin initiation and titration process

Targets2,3

Fasting blood glucose

  • Usual: 4.0-7.0 mmol/L (if A1C is not at target, consider a target of 4.0-5.5 mmol/L, balanced against the risk of hypoglycemia)
  • Functionally dependent/frail:* targets may be relaxed

See Insulin prescription for examples53

*Functionally dependent patients have a Clinical Frailty Scale8 score of 4-5 on a 9-point scale. Patients with frailty have a Clinical Frailty Scale8 score of 6-8 on a 9-point scale

Support patients to self-monitor
  • Fasting blood glucose and 2-hour post-prandial blood glucose (See Selfmonitoring blood glucose frequency and pattern tool48 for individualized timing)
  • Blood glucose levels in the middle of the night (1-2 times/month) to determine if they are experiencing nocturnal hypoglycemia54
Managing other medications when starting basal insulin
  • Stop thiazolidinediones (e.g., pioglitazone)
  • Reduce secretagogue (e.g., gliclazide, glyburide, repaglinide) ≥ 50%
  • Adjust other medications on a patient-by-patient basis11,56
  • Continue metformin, and if applicable, GLP1-RA, SGLT2i or DPP4i unless contraindicated
    • Metformin reduces insulin requirements, weight gain, morbidity and mortality2

 

Initiating and titrating flow chart
Targets2,3

Fasting blood glucose

  • Usual: 4.0-7.0 mmol/L (if A1C is not at target, consider a target of 4.0-5.5 mmol/L, balanced against the risk of hypoglycemia)
  • Functionally dependent/frail:** targets may be relaxed

Pre-prandial blood glucose

  • Usual: 4.0-7.0 mmol/L
  • Functionally dependent:** 5.0-8.0 mmol/L
  • Frail/dementia:** 6.0-9.0 mmol/L

Post-pandial blood glucose

  • Usual: 5.0-10.0 mmol/L
  • Functionally dependent:** < 12.0 mmol/L
  • Frail/dementia:** < 14.0 mmol/L

See Insulin prescription for examples53

*As effective as starting prandial insulin at all meals, but with lower risk of hypoglycemia and greater patient satisfaction at 1 year.57
** Functionally dependent patients have a Clinical Frailty Scale8 score of 4-5 on a 9-point scale. Patients with frailty have a Clinical Frailty Scale8 score of 6-8 on a 9-point scale.

Support patients to self-monitor
  • Fasting blood glucose and 2-hour post-prandial blood glucose (See Self-monitoring blood glucose frequency and pattern tool48 for individualized timing)
  • Blood glucose levels in the middle of the night (1-2 times/month) to determine if they are experiencing nocturnal hypoglycemia54
Managing other medications when starting basal insulin
  • Stop sulfonylureas, meglitinides and fixed-ratio combinations2
  • Continue metformin, and if applicable, GLP1-RA, SGLT2i or DPP4i unless contraindicated
    • Metformin reduces insulin requirements, weight gain, morbidity and mortality2

 

Initiating and titrating flow chart
Targets2,3

Fasting blood glucose

  • Usual: 4.0-7.0 mmol/L (if A1C is not at target, consider a target of 4.0-5.5 mmol/L, balanced against the risk of hypoglycemia)
  • Functionally dependent/frail:* targets may be relaxed

Pre-prandial blood glucose

  • Usual: 4.0-7.0 mmol/L
  • Functionally dependent:* 5.0-8.0 mmol/L
  • Frail/dementia:* 6.0-9.0 mmol/L

Post-pandial blood glucose

  • Usual: 5.0-10.0 mmol/L
  • Functionally dependent:* < 12.0 mmol/L
  • Frail/dementia:* < 14.0 mmol/L

See Insulin prescription for examples53

*Functionally dependent patients have a Clinical Frailty Scale8 score of 4-5 on a 9-point scale. Patients with frailty have a Clinical Frailty Scale8 score of 6-8 on a 9-point scale

 

Support patients to self-monitor
  • Fasting blood glucose and 2-hour post-prandial blood glucose (See Self-monitoring blood glucose frequency and pattern tool48 for individualized timing)
  • Blood glucose levels in the middle of the night (1-2 times/month) to determine if they are experiencing nocturnal hypoglycemia54
  • Blood glucose at least 2 times/day to safely titrate premixed insulin3
Managing other medications when starting basal insulin
  • Stop sulfonylureas (if on twice-daily premixed insulin), meglitinides, thiazolidinediones (e.g., pioglitazone) and duplicate insulins2,22
  • Consider dose reduction of agents other than metformin
  • Adjust other medications on a patient-by-patient basis11,56
  • Continue metformin, and if applicable, GLP1-RA, SGLT2i or DPP4i unless contraindicated
    • Metformin reduces insulin requirements, weight gain, morbidity and mortality2

 

Initiating and titrating flow chart

Switching Insulin New

How to switch insulin11,22

  • Confirm current insulin dose, including agent, concentration and dosage form used
  • Switching insulin often involves switching insulin pen devices
  • Counsel patients to temporarily increase the frequency of blood glucose monitoring during switch
  • Two approaches to switch insulin: 20% dose reduction or ‘unit-to-unit’

1. Switch insulin using a 20% dose reduction11,22

  • Use this technique (unless otherwise specified) to minimize the risk of hypoglycemia
  • May be used for the following insulin (100 units/mL unless otherwise specified)

The insulin on the left may be switched to the insulin on the right using a 20% dose reduction

  • Basal insulin (twice daily dose)
  • Degludec (Tresiba®)
  • Degludec (Tresiba®)
  • Detemir (Levemir®)
  • Glargine (BasaglarTM, Lantus®)
  • Glargine 300 units/mL (Toujeo®)
  • (if >80 units/day, consider twice daily dosing)
  • Degludec (Tresiba®)
  • Detemir (Levemir®)
  • Glargine (BasaglarTM, Lantus®)
  • NPH (Humulin® N, Novolin®ge) (consider dividing to twice-daily dosing)
  • Glargine 300 units/mL (Toujeo®)
  • Degludec (Tresiba®)
  • Detemir (Levemir®)
  • Glargine (BasaglarTM, Lantus®)

2. Switch insulin ‘unit-to-unit’11,22

  • May be used for the for the following insulin (100 units/mL unless otherwise specified)

The insulin on the left may be switched to the insulin on the right using a 20% dose reduction

  • Basal insulin (once daily dose)​

  • Degludec (Tresiba®)(unless A1C ≤7%, then decrease dose by 20%)
  • Basal insulin

  • Premixed insulin (consider a dose 10-20% lower than existing basal and prandial doses)
  • Glargine (Basaglar™, Lantus®)

  • Glargine 300 units/mL (Toujeo®)
  • Glargine (Lantus®)
  • Glargine (BasaglarTM)
  • Lispro (Humalog®)
  • Lispro (Admelog®)
  • NPH (Humulin® N, Novolin®ge)
  • Degludec (Tresiba® 100 units/mL only)
  • Detemir (Levemir®)
  • Glargine (BasaglarTM, Lantus®)
  • (unless NPH twice-daily dose, then decrease dose by 20%)
  • Regular insulin (Humulin® R, Novolin®ge Toronto)
  • Aspart (Novorapid®, Fiasp®)
  • Glulisine (Apidra®)
  • Lispro (Humalog®, Admelog®)
  • >200 units/day of basal, prandial or premixed insulin
  • Regular insulin 500 units/mL (Entuzity®) (unless A1C ≤8%, then decrease dose by 20%)

Section D: Managing hypoglycemia

Section E: Complex situations

Resources New

References New

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