Insulin Management Guide — GCC Nursing Reference

Insulin Classification & Pharmacokinetics

Class	Brand (GCC)	Onset	Peak	Duration	Key Use
Rapid-acting	Novorapid (Aspart) Humalog (Lispro) Apidra (Glulisine)	10–20 min	1–3 h	3–5 h	Mealtime bolus; given immediately before or after meal
Short-acting	Actrapid (Regular) Humulin R	30 min	2–4 h	6–8 h	IV infusions (DKA, ICU); SC 30 min before meals
Intermediate	Insulatard (NPH) Humulin N	1–3 h	6–10 h	12–20 h	Basal coverage; often combined with rapid-acting
Long-acting	Lantus (Glargine) Levemir (Detemir)	2 h	No peak	~24 h	Once-daily basal; predictable flat profile
Ultra-long	Toujeo (Glargine U-300) Tresiba (Degludec)	2–4 h	No peak	>24 h	Once-daily; reduced hypo risk; do NOT convert unit-for-unit from Lantus
Premixed	Mixtard 30 (70/30) Novomix 30 Humalog Mix 25/50	30 min	Dual	Up to 24 h	BD dosing; less flexible; do NOT use in hospitals for fine control

GCC market: Novo Nordisk (Novorapid, Actrapid, Insulatard, Levemir, Tresiba) and Eli Lilly (Humalog, Humulin) dominate UAE, Saudi Arabia, and Qatar formularies. Confirm local hospital formulary.

Insulin Concentrations — Safety Critical

HIGH ALERT MEDICATION High-concentration insulins cause fatal overdose if miscalculated. Always confirm concentration before administration.

Concentration	Units/mL	Notes
U-100	100 units/mL	Standard — most hospital insulins
U-200	200 units/mL	Tresiba U-200; use dedicated pen only
U-300	300 units/mL	Toujeo; 1 unit pen = 0.33 units U-100
U-500	500 units/mL	Humulin R U-500; severe insulin resistance only; 5× overdose risk with U-100 syringe

Storage Guidelines

Unopened vials/pens: Refrigerate 2–8°C; do NOT freeze; protect from light
In-use Novorapid/Actrapid: Room temp up to 28 days (max 30°C)
In-use Lantus: Room temp up to 28 days
In-use Levemir: Room temp up to 42 days
In-use Toujeo: Room temp up to 42 days; do NOT refrigerate once open
In-use Tresiba: Room temp up to 56 days (longest shelf-life)

GCC Climate Alert Ambient temps in UAE/Saudi/Qatar regularly exceed 45°C. Advise patients to store insulin in cool bags during outdoor activities and never leave in parked cars.

GCC Brand Equivalence Reference

Generic Name	Novo Nordisk Brand	Eli Lilly Brand	Class
Insulin Aspart	Novorapid	—	Rapid
Insulin Lispro	—	Humalog	Rapid
Insulin Glulisine	—	Apidra (Sanofi)	Rapid
Regular Insulin	Actrapid	Humulin R	Short
NPH Insulin	Insulatard	Humulin N	Intermediate
Insulin Glargine	Lantus (Sanofi)	Basaglar (biosimilar)	Long
Insulin Detemir	Levemir	—	Long
Insulin Degludec	Tresiba	—	Ultra-long

Basal-Bolus Regimen — Gold Standard Inpatient

Basal

Lantus or Levemir once daily at fixed time — do NOT omit even if fasting

Bolus

Novorapid/Humalog with each meal — HOLD if patient not eating

Correction

Sliding scale for BGL out of target — added to meal bolus

Key Principle Basal insulin replaces overnight and fasting background secretion. It is NOT adjusted for meals. Bolus insulin covers postprandial glucose. Never use sliding scale alone as the primary regimen — it is reactive, not proactive.

Correction Dose Calculator

Current Blood Glucose (mmol/L)

Target Blood Glucose (mmol/L)

Patient Weight / ISF

—

units of rapid-acting insulin

Formula: Correction Dose = (Current BGL − Target BGL) ÷ ISF

Always round to nearest whole unit
Maximum single correction dose: typically 10 units — verify with physician
Do not stack corrections — wait minimum 3 hours between doses
ISF varies with illness, steroids, infection — reassess daily

Ramadan Insulin Adjustments — GCC Critical Content

Cultural Context During Ramadan, Muslim patients fast from Fajr (pre-dawn) to Maghrib (sunset), approximately 12–16 hours. Most T2DM patients are not required to fast by Islamic rulings if medically unsafe, but many choose to. Engage respectfully with patient and family.

Suhoor (Pre-Dawn Meal)

Larger, complex-carbohydrate meal taken just before Fajr
Rapid-acting insulin: give dose at Suhoor time, not earlier
Consider reducing dose by 20–30% to avoid hypoglycaemia mid-fast
BGL check at Suhoor and 2 hours after

Iftar (Post-Fast Meal)

Meal taken at Maghrib (sunset) — give rapid-acting insulin at Iftar time
Meal often high glycaemic index (dates, juices) — monitor for postprandial spike
May need slightly increased bolus if large high-GI meal consumed
Check BGL 1–2 hours post-Iftar

Basal Insulin During Ramadan

Lantus/Glargine: Consider shifting dose to Iftar time (sunset); reduce by 20% initially
Levemir: Can split into BD; give smaller dose at Suhoor, larger at Iftar
Toujeo/Tresiba: Discuss with endocrinologist — ultra-long profile may require careful timing
Never omit basal completely, especially Type 1 DM

Sick Day Rules During Ramadan

BGL >16 mmol/L: patient advised to break fast and seek medical advice
BGL <4 mmol/L: patient must break fast (Islamic ruling permits)
Symptomatic hypoglycaemia: immediate treatment, fast must be broken
Vomiting, illness, BGL fluctuations: advise patient to break fast
Document BGL three times daily minimum during Ramadan admission

Injection Technique & Site Rotation

Absorption Rate by Site (Fastest → Slowest)

Abdomen — Fastest; preferred for mealtime insulin; avoid 5 cm around navel
Deltoid (upper arm) — Medium; convenient for self-injection
Outer thigh — Slower; suitable for basal insulin
Buttock — Slowest; least prone to lipohypertrophy

Use Z-pattern or 2 cm grid rotation within each site to prevent lipohypertrophy

Technique Checklist

1Wash hands; use clean needle for each injection
2Inspect insulin — no cloudiness in clear insulins, no particles
3Prime pen 2 units before each use
4Angle: 90° for normal/overweight BMI; 45° for thin patients (BMI <20)
5Skin pinch: use for 4 mm needles in thin patients
6Hold needle in 10 seconds after injecting to prevent leakage
7Pen needles preferred: 4–6 mm for most adults
8Dispose in sharps bin — do NOT recap pen needles

Never share insulin pens — even between the same patient with different needles. Risk of blood-borne pathogen transmission. Each patient must have their own pen.

Indications for IV Insulin Infusion

DKA — diabetic ketoacidosis (primary indication)
HHS — hyperosmolar hyperglycaemic state (use carefully)
Post-cardiac surgery — tight glucose control 6–8 mmol/L
NPO with Type 1 DM — cannot omit insulin even if fasting
Critical illness hyperglycaemia — glucose persistently >10 mmol/L
Hyperglycaemic crisis in ICU/HDU settings
Perioperative — major surgery in insulin-dependent DM

Standard IV Insulin Preparation

Standard Concentration: 1 unit/mL Add 50 units Actrapid (Regular) to 50 mL 0.9% Sodium Chloride. Use a dedicated syringe pump. Label clearly: "INSULIN INFUSION — 1 unit/mL".

Use only Regular/Short-acting insulin (Actrapid, Humulin R) for IV — never long-acting or rapid-acting analogue
Insulin adsorbs to plastic tubing — flush 20 mL before use to saturate binding sites
Change syringe every 24 hours or per hospital policy
Maintain dedicated IV line for insulin if possible
Always co-administer dextrose-containing fluid to prevent hypoglycaemia

Glucose Target Ranges (ICU)

6–10

mmol/L — General ICU target (ADA 2024)

6–8

mmol/L — Post-cardiac surgery (CABG/valve)

7–10

mmol/L — Non-critical ward setting

Intensive control (4–6 mmol/L) is NOT recommended — NICE-SUGAR trial showed increased mortality with tight control. Avoid hypoglycaemia; it is independently associated with poor outcomes in critical care.

IV Insulin Titration Protocol

Monitor BGL hourly when initiating infusion. Extend to every 2 hours when BGL stable within target range for 4 consecutive readings.

BGL (mmol/L)	Action	Recheck In	Additional Notes
< 4.0	STOP infusion immediately; give 150 mL 10% dextrose IV; notify physician	15 minutes	If <3 mmol/L: 50 mL 50% dextrose IV; do NOT restart until BGL >6
4.0 – 6.0	Reduce infusion rate by 50%	1 hour	Ensure dextrose co-infusion running; if patient symptomatic treat as hypo
6.0 – 10.0	Maintain current rate — target achieved	1–2 hours	Extend monitoring interval to 2h once stable ×4 readings
10.0 – 14.0	Increase infusion rate by 25%	1 hour	Review fluid regimen; exclude new infection, steroids, TPN as cause
> 14.0	Increase infusion rate by 50%; notify physician	1 hour	Consider IV fluid review; check ketones; exclude DKA/HHS trigger

Hypoglycaemia Management (ICU)

1Stop insulin infusion immediately — do not delay
2If awake and cooperative: 15–20 g oral glucose (150 mL juice)
3If unconscious/IV access: 50 mL 50% dextrose (25 g) IV push — flush line
4Alternative: 150 mL 10% dextrose IV over 15 min (preferred — less vein trauma)
5No IV access: Glucagon 1 mg IM (less effective if malnourished/liver disease)
6Recheck BGL in 15 minutes; repeat treatment if still <4 mmol/L
7Restart infusion at 50% of previous rate when BGL >6 mmol/L
8Notify physician; complete incident report; review insulin protocol

Transition IV → Subcutaneous Insulin

Critical Overlap Rule Administer first SC dose (basal insulin) at least 1–2 hours BEFORE stopping IV infusion. This prevents insulin gap and rebound hyperglycaemia. Failure to overlap is a common cause of post-ICU hyperglycaemic crises.

Transition Checklist

Patient must be haemodynamically stable, tolerating oral or enteral feeds
Estimate 24-hour IV insulin requirement from previous 6–8 hours
Convert: total daily IV dose × 0.8 = total daily SC dose (20% reduction for safety)
Divide: 50% as basal (Lantus), 50% as bolus split across 3 meals
Check BGL 1h, 2h, and 4h after transition — monitor closely
Document: reason for transition, dose calculation, timing of overlap

Hypoglycaemia Classification & Treatment

Hypoglycaemia Defined: BGL < 4.0 mmol/L (< 70 mg/dL) Any value below 4.0 requires immediate action regardless of symptoms. Clinically significant hypoglycaemia = <3.0 mmol/L (<54 mg/dL).

Level	BGL	Clinical Picture	Treatment
Mild	3.0–3.9 mmol/L	Conscious, cooperative, able to swallow safely; tremor, sweating, hunger, palpitations	15g fast-acting carbohydrate: 4 glucose tablets OR 150 mL fruit juice OR 3 jelly beans OR 200 mL regular (non-diet) cola
Moderate	2.0–2.9 mmol/L	Confused, uncooperative, unable to follow commands safely, but some consciousness present	IV 50% dextrose 50 mL OR glucagon 1 mg IM/SC — do NOT attempt oral if swallow unsafe
Severe	< 2.0 mmol/L	Unconscious, seizure, unresponsive	IV 50% dextrose 50 mL; airway protection; call for help (MET/code); glucagon 1 mg IM if no IV

Rule of 15 Protocol

15g

Fast-acting carbohydrate given

15 min

Wait before rechecking BGL

4.0

Target mmol/L — retreat if below

After BGL >4.0: give a snack containing complex carbohydrate + protein (e.g. 2 plain biscuits and milk) to sustain recovery. Schedule follow-up meal within 1 hour.

Post-Hypoglycaemia Actions

Identify and document precipitating cause
Review insulin dose, timing, meal intake
Check for missed or delayed meals, increased activity
Review concomitant medications (quinolones, salicylates, beta-blockers can mask symptoms)
Complete incident report if medication-induced
Notify treating physician; consider dose reduction
Patient/family education if recurrent

Common GCC-Context Causes

Ramadan fasting: delayed or missed meals with unchanged insulin dose
Prayer activity: post-prayer physical activity unexpected
Delayed hospital meals — bolus given but meal not delivered
Steroid taper — dose reduced but insulin not adjusted
Renal impairment — reduced insulin clearance increases half-life
NPO for procedure — bolus given, procedure delayed

Hyperglycaemia Management

BGL (mmol/L)	Nursing Action	Escalation
10–14	Document; administer correction dose per protocol; assess for cause	If persistent >2 readings, notify physician
14–20	Correction dose; check for ketones (T1DM or T2DM on insulin); increase monitoring frequency	Notify physician; review insulin regimen
> 20	Stop oral intake; check ketones, blood gas, electrolytes; IV access	Urgent physician review; consider IV insulin protocol
> 25 + symptoms	Prepare for IV fluid and IV insulin; monitor urine output	ICU/HDU assessment; rule out DKA/HHS

DKA vs HHS — Quick Differentiation

Feature	DKA	HHS
Blood Glucose	>11 mmol/L (often 15–30)	>33 mmol/L (often 50–70)
Serum Osmolality	Normal or mildly elevated (<320)	>320 mOsm/kg (often 350+)
Arterial pH	<7.3	>7.3 (normal)
Bicarbonate	<15 mmol/L	>18 mmol/L
Ketones	++ / +++ (urine & blood)	Negative or trace
Anion Gap	Elevated (>12)	Normal
Onset	Hours (24–48h)	Days to weeks
Typical Patient	Type 1 DM, younger, known DM	Type 2 DM, elderly, may be newly diagnosed
Primary Treatment	IV insulin + IV fluids + K+ replacement	Slow IV fluid replacement; cautious insulin
Fluid Rate	1L over 1h, then reassess	Slower: 0.5L/h initially — avoid rapid shifts
Potassium	Give K+ if <5.5 before insulin	Monitor carefully; slower correction

DKA Criteria (all three must be present): BGL >11 mmol/L + pH <7.3 or HCO3 <15 + ketonaemia/ketonuria ++ or blood ketones >3 mmol/L

HHS Red Flag: Osmolality >320 mOsm/kg. Rapid fluid replacement causes cerebral oedema — reduce osmolality no faster than 3–8 mOsm/kg/hour. Heparin thromboprophylaxis essential — high thrombosis risk.