close

Log in

Access to premium content is restricted to healthcare professionals / registered members. Login with your email address to continue.

Forgot Your Password?

Don't have an account? Sign up

By signing in or creating an account, you agree to our Terms and conditions and Privacy notice

This site is intended for Healthcare Professionals only
Back to CKS

Drugs and devices Endocrine and metabolic

Insulin therapy in type 1 diabetes

Last revised in July 2025

Insulin is a polypeptide hormone secreted by pancreatic beta-cells.The role of insulin is to lower blood glucose to prevent hyperglycaemia

Insulin therapy in type 1 diabetes: Summary

  • Insulin is a polypeptide hormone secreted by pancreatic beta cells. Its role is to lower blood glucose levels.
  • In people with type 1 diabetes, autoimmune destruction of pancreatic beta cells results in absolute insulin deficiency.
  • Insulin therapy for people with type 1 diabetes should only be initiated and managed by healthcare professionals with the relevant expertise and training.
  • Insulins are broadly categorized according to their time-action profiles:
    • Rapid- and short-acting insulins have a quick onset of action and a short duration of action. They are used to replicate endogenous insulin secretion in response to a meal or sugary drink.
    • Intermediate- and long-acting insulins have a slow onset of action and a long duration of action. They mimic the effect of endogenous basal insulin secreted continuously throughout the day.
  • There are different types of insulin regimens which should be individualized for each person with type 1 diabetes:
    • Multiple daily injection basal-bolus regimen — offered first-line to all adults and children.
    • Mixed insulin regimen — offered second-line to adults.
    • Insulin pump therapy — may be offered to some adults and children experiencing disabling hypoglycaemia or if HbA1c levels remain high despite best possible management.
    • Hybrid closed loop systems — may be offered if an adult experiences disabling hypoglycaemia or HbA1c levels remain high despite best possible management with insulin pump therapy and/or continuous glucose monitoring (CGM).
  • People on insulin therapy and/or family/carers should be advised about:
    • Sources of information and support.
    • Injection technique and sites, injection site problems, and insulin storage.
    • Blood glucose self-monitoring, including when to test, and how to interpret and respond to results. All people should have the equipment to do capillary blood glucose monitoring, regardless of whether they are using CGM, to check the accuracy of their CGM device and as a back-up.
    • Awareness and emergency management of hypoglycaemia (glucose levels less than 3.9 mmol/L); hypoglycaemia symptoms; when treatment with fast-acting oral carbohydrates, intramuscular glucagon, or intravenous glucose is needed and when to ring 999; and implications of hypoglycaemia and hypoglycaemia awareness for driving and other risk-critical activities.
    • Seeking urgent medical review if hypoglycaemia becomes problematic or increases in frequency, to assess for possible contributory causes or risk factors to prevent further episodes.
    • Always wearing or carrying some form of diabetes identification.
    • Notifying the Driver and Vehicle Licensing Agency if they drive, and the rules for blood glucose monitoring.
    • Managing diabetes during a period of intercurrent illness.
    • Lifestyle and cultural issues, including diet and exercise, alcohol intake, driving, fasting, employment and shift work, holidays and travel, and insurance.

Have I got the right topic?

From age 12 months onwards.

This CKS topic covers general information on insulin therapy for people with type 1 diabetes.

This CKS topic does not provide detailed information on insulin initiation, dose adjustments, or regimen changes, as insulin therapy should only be initiated and managed by healthcare professionals with the relevant expertise and training.

This CKS topic does not cover insulin treatment for women who are pregnant or breastfeeding, or detailed information on animal insulins (which are rarely used). It also does not cover general management or lifestyle advice for people with type 1 diabetes.

There are separate CKS topics on Diabetes - Type 1, Diabetes - type 2, and Insulin therapy in type 2 diabetes.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2025 — reviewed. A literature search was conducted in March 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations have been updated in line with current evidence in the literature, specifically the indications for insulin pump therapy, continuous glucose monitoring (CGM), and the definition of what blood glucose level constitutes an alert value for hypoglycaemia.

Previous changes

October 2024 — minor update. Information about hybrid closed loop systems has been incorporated into this topic in line with the National Institute for Health and Care Excellence (NICE) technology appraisal Hybrid closed loop systems for managing blood glucose levels in type 1 diabetes (2023).

April 2023 — minor update. Information about continuous glucose monitoring was revised to align with the CKS topic on Diabetes - type 1 topic and the NICE guideline Type 1 diabetes in adults: diagnosis and management (2022).

August 2020 — minor update. Rotation of injection sites for insulin therapy section has been updated in line with the manufacturers' revised Summary of Product Characteristics (SPC). 

July 2020 — reviewed. A literature search was conducted in May 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to recommendations have been made.

February 2016 — reviewed. A literature search was conducted in November 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. The recommendations have been updated in line with recommendations in the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2015] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2015].

June 2015 — minor update. Links to the NICE guidelines have been amended, and minor typographical errors have been corrected.

May 2015 — minor update. Typographical errors corrected, and recommendations on the management of diabetic ketoacidosis clarified.

April 2015 — reviewed. A literature search was conducted in March 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made. The advice for driving has been changed in line with the updated Driver and Vehicle Licensing Agency (DVLA) guidance for people with diabetes mellitus. The topic has been restructured, and the scope has been clearly defined.

August 2014 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a medical device alert stating that Accu-Chek Compact®, Accu-Chek Mobile®, and Accu-Chek Active® devices and test strips may give falsely low blood glucose readings in people receiving ceftriaxone treatment.

July 2013 — minor update. Links to the DVLA website have been updated.

April 2012 — minor update. Links to local policies on when to initiate changes in insulin doses have been updated.  Information from the guideline Recognition, treatment and prevention of hypoglycaemia in the community commissioned by NHS Diabetes has been added to the text. 

December 2011 — minor update. Information on fitness to drive from the DVLA guidance for medical practitioners At a glance guide to the current medical standards of fitness to drive has been added to this topic. 

June 2011 — minor update. A section on Insulin passports has been added to the section on Prescribing information following the National Patient Safety Agency patient safety alert on safer use of insulin. 

September to December 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2025.

New policies

No new national policies or guidelines since 1 March 2025.

New safety alerts

No new safety alerts since 1 March 2025.

Changes in product availability

No changes in product availability since 1 March 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Be aware of the different insulin products and regimens available.
  • Identify the most appropriate insulin product and ensure that people receive appropriate training on correct use. 
  • Ensure that people receiving insulin therapy are given information on hypoglycaemia awareness and management.
  • Manage other adverse effects of insulin therapy, such as injection site problems.
  • Educate people receiving insulin therapy about 'sick-day rules'.
  • Provide information and advice on lifestyle and cultural aspects of insulin therapy, including diet and exercise, alcohol intake, driving, holiday and travel, insurance, fasting, and shift work.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is insulin?

  • Insulin is a polypeptide hormone secreted by pancreatic beta cells.
    • The role of insulin is to lower blood glucose levels to prevent hyperglycaemia and associated microvascular complications (retinopathy, nephropathy, and neuropathy), macrovascular complications (cardiovascular disease, cerebrovascular disease, and peripheral arterial disease), and metabolic complications (diabetic ketoacidosis). It achieves this by increasing glucose uptake (by adipose tissue and muscles) and suppressing hepatic glucose release.
  • The natural profile of insulin secretion consists of two components:
    • Basal insulin — this corresponds to the low and steady level of background insulin in the body. This insulin secretion is necessary to control the glucose that is continuously released from the liver, which is relatively constant, although it typically declines slightly during the night and peaks before dawn.
    • Meal-time bolus insulin — insulin secretion sharply increases in response to glucose absorbed from an ingested meal or sugary drink. 
  • In people with type 1 diabetes, autoimmune destruction of pancreatic beta cells results in absolute insulin deficiency. Consequently, insulin therapy is a medical necessity to prevent metabolic decompensation and diabetic ketoacidosis.
    • See the CKS topic on Diabetes - type 1 for detailed information on managing people with type 1 diabetes.

 [Holt, 2021; Rahman, 2021; Cengiz, 2024] 

Management

Scenario: Insulin therapy - type 1 diabetes

From age 12 months onwards.

Which insulin products are available?

  • Three types of insulin are available in the UK:
    • Human insulins are produced by recombinant DNA technology and have the same amino acid sequence as endogenous human insulin.
    • Human insulin analogues are produced in the same way as human insulins, but the insulin is modified to produce a specific desired kinetic characteristic (such as an extended duration of action or faster absorption and action).
    • Animal insulins are extracted and purified from animal sources, such as cows (bovine insulin) or pigs (porcine insulin).
      • Although widely used in the past, animal insulins are no longer initiated in people with diabetes. However, they are still used in some people who cannot, or do not wish to, change to human insulins. These insulins are not covered in the scope of this CKS topic.
  • Insulins are broadly categorized according to their time-action profiles.
    • Rapid- and short-acting insulins have a quick onset of action and a short duration of action. They are used to replicate endogenous insulin secretion in response to a meal or sugary drink.
      • Rapid-acting insulins have an onset of action of about 15 minutes and a duration of action of 2–5 hours. Examples include Humalog® (insulin lispro) and NovoRapid® (insulin aspart). They may also be needed to manage blood sugar levels during intercurrent illness or episodes of hyperglycaemia.
      • Short-acting (regular or neutral) insulins have an onset of action of 30–60 minutes and a duration of action of up to 8 hours. Examples include Actrapid® and Humulin S®.
      • They are used in insulin pumps.
    • Intermediate- and long-acting insulins have a slow onset of action and a long duration of action. They mimic the effect of endogenous basal insulin (which is secreted continuously throughout the day).
      • Intermediate-acting (isophane) insulins have an onset of action of approximately 1–2 hours, maximal effects between 3–12 hours, and a duration of action of 11–24 hours. Examples include Humulin I® and Insulatard®.
      • Long-acting insulins have a duration of action of up to 24 hours, and a steady-state level is achieved after 2–4 days. Examples include Lantus® (insulin glargine), Levemir® (insulin detemir), and Tresiba® (insulin degludec).
  • Several new insulin products have been launched in recent years.
    • High-strength insulins have concentrations greater than 100 units/mL and have been developed for people with large daily insulin requirements to reduce the number and volume of injections. Examples include Tresiba® (200 units/mL), Humalog® (200 units/mL), and Toujeo® (300 units/mL).
    • Biosimilar insulin is a biological copy of an original insulin. Abasaglar® is a biosimilar insulin product based on insulin glargine 100 units/mL (Lantus®) and is licensed for the treatment of diabetes in adults, adolescents, and children aged 2 years and older.
    • Warn the person only to use insulin as they have been trained, because using it any other way may result in a dangerous overdose or underdose.
  • When prescribing, ensure that insulins are prescribed by brand name.
  • For detailed information about different insulin products, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).
  • Further information for patients on Insulin and diabetes is available on the Diabetes UK website (www.diabetes.org.uk). 

Basis for recommendation

This information is based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024], the Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update High strength, fixed combination and biosimilar insulin products: minimising the risk of medication error [MHRA, 2015], and expert opinion in the British National Formulary (BNF) [BNF, 2025].

Insulin therapy for people with type 1 diabetes should only be initiated and managed by healthcare professionals with the relevant expertise and training.

  • There are different types of insulin regimens:
    • Multiple daily injection basal-bolus regimen — the person has injections of short-acting insulin or rapid-acting insulin analogue before meals, together with one or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue to cover the basal requirement. This regimen offers greater flexibility for blood glucose control, such as variable or unpredictable eating patterns in some people.
    • Mixed insulin regimen — the person has one, two, or three insulin injections per day of short-acting insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin. The insulin preparations may be mixed by the person at the time of injection, or a premixed product can be used.
    • Continuous subcutaneous insulin infusion (insulin pump) therapy — this is a programmable pump and insulin storage device that gives a regular or continuous amount of insulin (usually in the form of a rapid-acting insulin analogue or short-acting insulin) by a subcutaneous needle or cannula.
      • The pump can be programmed to deliver different basal rates of insulin at different times of the day and night, with higher infusion rates triggered by the push of a button at mealtimes. The insulin requirement can be matched more closely to the person's basal requirement, pre-prandial glucose levels, carbohydrate intake, and physical activity.
      • Insulin pump therapy should only be initiated by a trained specialist team, such as a physician with a specialist interest in insulin pump therapy, a diabetes specialist nurse, and a dietician, who provide specific training on its use and ongoing support for the person and/or family/carers.
    • Hybrid closed loop systems — this is an insulin pump, continuous glucose sensor, and an algorithm, which controls basal insulin delivery and, in some cases, correction boluses, based on continuous glucose monitoring (CGM) data. These are the most effective means of maintaining glucose in the normal range in people with type 1 diabetes. See the section on Blood glucose monitoring for more information on CGM.
  • See the sections on Adult insulin regimens and Child and young people insulin regimens for more information on recommended insulin regimens in different age-groups.

Adult insulin regimens

Insulin therapy for adults with type 1 diabetes should only be initiated and managed by healthcare professionals with the relevant expertise and training. 

  • Offer multiple daily injection basal-bolus insulin regimens first-line to all adults with type 1 diabetes.
    • Offer twice-daily insulin detemir as the long-acting basal insulin therapy, unless:
      • The person is achieving their agreed HbA1c treatment target, or time in target glucose range and minimizing hypoglycaemia, on an existing insulin regimen, continue on that regimen.
      • Insulin detemir is not tolerated or the person has a strong preference for once-daily basal injections, offer once-daily insulin glargine (100 units/mL).
      • There is a particular concern about nocturnal hypoglycaemia, offer once-daily insulin degludec (100 units/mL).
      • The person needs help from a carer or healthcare professional to administer injections, offer once-daily ultra-long-acting insulin, such as degludec (100 units/mL).
      • The recommendations above do not meet agreed treatment targets. Consider other basal insulin regimens, taking into account the person's comorbidities, adherence, preferences, and acquisition cost.
      • The person is already using an insulin for which a lower cost biosimilar is available, discuss the possibility of switching to the biosimilar using shared decision making.
    • Offer a rapid-acting insulin analogue injected before meals for mealtime insulin replacement (rather than rapid-acting soluble human or animal insulins).
      • Do not advise routine use of rapid-acting insulin analogues after meals.
      • If the person has a strong preference for an alternative mealtime insulin, offer the preferred insulin, depending on clinical judgement.
  • If a multiple daily injection basal-bolus insulin regimen is not possible, consider a twice-daily human mixed insulin regimen.
    • Consider a trial of a twice-daily analogue mixed insulin regimen if the person has hypoglycaemia that affects their quality of life. See the section on Managing hypoglycaemia more information.
  • Insulin pump therapy is recommended for some adults with type 1 diabetes mellitus if:
    • Attempts to achieve the agreed treatment HbA1c target with multiple daily injection therapy result in the person experiencing disabling hypoglycaemia, or
    • HbA1c levels remain high (69 mmol/mol or above) on multiple daily injection therapy (including, if appropriate, the use of long-acting insulin analogues) and best possible management.
  • A hybrid closed loop system is recommended as an option for managing blood glucose levels in adults with type 1 diabetes who have an HbA1c of 58 mmol/mol or more, or have disabling hypoglycaemia, despite best possible management with at least one of the following:
    • Insulin pump therapy.
    • Real-time continuous glucose monitoring (rtCGM).
    • Intermittently scanned continuous glucose monitoring (isCGM).

Child and young people insulin regimens

Insulin therapy for children and young people with type 1 diabetes should only be initiated and managed by healthcare professionals with the relevant expertise and training. The choice of insulin regimen and insulin delivery system should take into account the personal and family circumstances of the child or young person as well as their preference and that of their family/carers.

  • Multiple daily injection basal-bolus insulin regimens should be offered to children and young people with type 1 diabetes from diagnosis.
    • Encourage the child and/or family/carers to adjust the insulin dose if needed after each blood glucose measurement.
    • Advise to inject a rapid-acting insulin analogue before eating (rather than after eating) to reduce blood glucose levels after meals and help to optimize blood glucose control.
  • If a child or young person is using a mixed insulin regimen with twice-daily injections, advise to adjust the insulin dose according to the general trend in pre-meal, bedtime, and occasional night-time blood glucose levels.
  • Insulin pump therapy may be recommended for some children and young people with type 1 diabetes aged 12 years and over if:
    • Attempts to achieve the agreed treatment HbA1c target with multiple daily injection therapy result in the person experiencing disabling hypoglycaemia, or
    • HbA1c levels remain high (69 mmol/mol or above) on multiple daily injection therapy (including, if appropriate, the use of long-acting insulin analogues) and best possible management.
  • Insulin pump therapy may be recommended for some children with type 1 diabetes younger than 12 years if a multiple daily injection regimen is considered impractical or inappropriate.
  • If the child or young person does not have optimal blood glucose control:
    • Ensure the person is reviewed by the diabetes specialist team for follow-up as clinically appropriate. An alternative insulin regimen may be offered, following specialist review.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023] and the NICE Technology Appraisal guidance Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus [NICE, 2008], together with the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024], and expert opinion in the British National Formulary (BNF) [BNF, 2025].

  • The ADA/EASD consensus report states that ideally a multiple daily injection regimen should be started in adults with type 1 diabetes, but insulin pump therapy or a hybrid closed loop system may be considered for some adults, depending on individual circumstances [Holt, 2021].
  • The ISPAD clinical practice consensus guidelines note that insulin dosing is affected by factors such as age, weight, growth, development, stage of puberty and menstrual cycles (if relevant), nutritional intake and distribution, exercise and daily routine, and intercurrent illness. Over time, the insulin regimen should be adjusted depending on the blood glucose response, growth, level of exercise, and changes in weight and insulin sensitivity. In addition, it notes that 'insulin treatment must be supported by comprehensive education appropriate for the age, maturity, and individual needs of the child and family regardless of the insulin regimen'. It further highlights that regular review and assessment are needed due to the changes in daily insulin dosage between individuals and over time [Cengiz, 2024].
  • The ISPAD clinical practice consensus guidelines state that an improvement in long-term blood glucose by intensified insulin therapy and extensive support and education, can reduce the incidence of complications and delay the progression of existing complications in type 1 diabetes in adolescents and adults. Multiple daily insulin injections and continuous subcutaneous insulin infusion by insulin pump allow some flexibility by 'partially accommodating variable eating patterns', and are the gold standard for the treatment of type 1 diabetes in children across all age-groups. Optimal blood glucose management for a person balances the prevention of hypoglycaemia and hyperglycaemia, while minimizing the risk of long-term complications. Automated insulin delivery aims to achieve a high level of treatment personalization, better blood sugar control, and empowerment for people with diabetes [Cengiz, 2024].
  • The NICE guideline on type 1 diabetes in children notes that regular contact with the diabetes team and attending planned reviews will help the child to maintain optimal blood glucose levels [NICE, 2023].

Which accessories for insulin therapy may be needed?

  • Insulin injection delivery device 
    •  A variety of insulin injection devices are available: standard insulin U100 syringes, preloaded disposable pens, reusable injection pens, needle-free injection devices, and continuous subcutaneous insulin infusion (insulin pump) therapy. 
    • The choice of device will depend on factors such as:
      • The age of the person.
      • Dexterity (for example, ease of inserting and changing cartridges). 
      • Any visual impairment (such as problems reading the dialled dose).
      • Needle phobia — a needle-free insulin device, such as InsuJet®, is a possible option for people with true and severe needle phobia (this is rare).
      • Inability to achieve target HbA1c — insulin pump therapy may be considered.
      • Personal choice.
  • Needles for pen injectors
    • Sterile disposable needles are available in different lengths (from 4 mm to 12.7 mm).
    • People having injection site problems (such as pain, local skin reactions, and injection site leakages) should be offered needles of a different length.
    • Provide children and young people with needles that are of appropriate length for their subcutaneous fat mass.
  • Blood glucose meter, test strips, and lancets for self-monitoring of blood glucose
    • Blood glucose monitoring meters are not prescribable on the NHS. However, some brands can be obtained free of charge from the diabetes specialist team or the manufacturer, or they can be purchased online or from pharmacies. The choice of blood glucose meter will depend on personal preference, cost, and/or the policy of the diabetes specialist team.
    • Single-use testing strips are prescribable on the NHS, and they are designed for use with specific proprietary blood glucose monitoring meters. Provide the person with enough test strips to take capillary blood glucose measurements as needed.
    • Single-use lancets are prescribable on the NHS. They are available in various lengths and gauges, and are designed to fit into proprietary finger-pricking devices (which are usually packaged with the blood glucose meter).
  • Ketone meter, test strips, and lancets 
    • Blood ketone meters are not prescribable on the NHS but can be purchased online or from pharmacies. Single-use blood ketone testing strips and single-use lancets are available on the NHS.
    • Urine ketone testing strips are prescribable on the NHS. 
  • Glucose and/or glucagon kit
    • Glucose 40% oral gel is available on prescription (and can also be purchased from pharmacies) for the treatment of hypoglycaemia in people who are able to swallow safely.
    • Glucagon 1 mg injection (GlucaGen® Hypokit) is available on prescription for the treatment of severe hypoglycaemia.
  • Accessories for sharps disposal
    • Used syringes, insulin pen devices (such as pre-filled pens), needles, and lancets must be safely stored and disposed of to prevent sharps-related injuries.
    • Sharps containers are also available on the NHS and come in different sizes: 
      • A 1 L sharps bin is suitable for most people.
      • A 5 L sharps bin is most suitable for people who have lancets, insulin pen needles, syringes, and insulin pump tubing and cannulas to dispose of. 
  • Insulin Passport and patient information booklet 
    • Adults on insulin therapy should be given an Insulin Passport and a patient information booklet.
      • The Insulin Passport provides a record of the person's current insulin preparations, and contains a section for emergency information.
      • The patient information booklet provides advice on the safe use of insulin.
  • Identification jewellery or card
    • Advise people with diabetes to always carry or wear some form of identification indicating that they have diabetes in an emergency, such as:

Basis for recommendation

This information is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024] and ISPAD Clinical practice consensus guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes [Abraham 2022], and expert opinion in the British National Formulary (BNF) [BNF, 2025].

How is insulin administered?

  • Insulin preparations are usually given by subcutaneous injection because insulin is destroyed by gastric acid and is not absorbed across the gut mucosa. Alternatively, it may be given by subcutaneous infusion via an insulin pump in some people.
  • There is considerable day-to-day variation in insulin absorption, particularly in children.
    • The rate of absorption can vary by as much as 20–40% from one day to the next in any person, owing to local tissue reactions, changes in insulin sensitivity, blood flow, depth of injection, and/or the amount of insulin injected.
    • Other factors that affect insulin absorption include:
      • Larger dose — absorption is slower if a large insulin dose is injected.
      • Accidental intramuscular injection (due to poor injection technique or the use of an inappropriate needle length) — injecting insulin into deeper intramuscular tissue can increase the variability of absorption and cause erratic blood glucose levels and hypoglycaemia.
      • Exercise — absorption is faster owing to increased blood flow at the injection site of the exercised region (for example thighs of runners).
      • Injection site — the rate of insulin absorption varies depending on which part of the body is used. This might have some effect on blood glucose control.
      • Age — absorption is faster in young children as they have less subcutaneous fat.
      • Fat mass — absorption is slower if there is a large amount of subcutaneous fat due to a reduction in subcutaneous blood flow.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024].

  • The ISPAD clinical practice consensus guidelines highlight the importance of using needles of the correct length for the person, as longer needles may increase the risk of intramuscular (IM) injections  [Cengiz, 2024].

What should I advise about insulin injection technique?

Injection technique should be checked regularly. Advise the person and/or parent/carers:

  • To leave insulin at room temperature for at least 30 minutes before injecting.
    • A longer period may be required for some insulins — advise the person to check the manufacturer's patient information leaflet (PIL).
    • Cold insulin (straight from the fridge) can make injection painful, and the insulin may take longer to absorb.
  • To check the expiry date of the product before administration.
  • To carefully read the manufacturer's PIL (or get advice from their diabetes specialist team) on how to use their specific product, including:
    • How to prepare the insulin before use.
      • If using cloudy insulin, they should gently roll (not shake) the pen at least 10 times in the palm of the hands and invert 10 times to mix the insulin.
    • How to prime the pen, if needed.
      • This should be done before each injection, to ensure that the plunger is connecting and any air is expelled from the pen.
  • To use a new needle for each injection.
  • To choose an appropriate injection site, ensuring that the site and hands are clean. 
    • Unless hygiene is a real problem, the use of alcohol wipes should be avoided as it can make the injection more painful and harden the skin. Infection at injection sites is rare.
    • Young children (less than 6 years of age) and adults with a body mass index (BMI) less than 19 should inject into a lifted skinfold using a two-finger pinch technique.
    • Injections should not be done through clothing as this will affect lubrication of the needle and also make it difficult to 'pinch up' the skin and to check for bleeding.
    • For people injecting more than 50 units of insulin (0.5 mL of U100 insulin), many experts recommend splitting the injection into separate areas to facilitate absorption.
  • That insulin should be injected with the needle at a 90° angle to the skin surface. The needle should be inserted quickly and all the way in to ensure injection at a consistent depth and to avoid intradermal injection.
    • A 4 mm needle length may be preferred, as it has a low risk of intramuscular injection and allows wider zones for rotation.
    • The needle should be left in the skin for 15 seconds (or longer for large doses) to ensure the entire dose is injected and to avoid leakage of the dose.
  • That after withdrawing the needle, they should apply gentle pressure over the injection site for several seconds. The area should not be rubbed as this may increase the rate of insulin absorption.
  • To store their insulin properly.

Basis for recommendation

These recommendations are based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024]. They are also pragmatic, based on what CKS considers to be good clinical practice.

  • The ISPAD clinical practice consensus guidelines note that insulin should be injected into subcutaneous tissue, as intramuscular injection can lead to more rapid and unpredictable insulin absorption and variable effects on blood glucose. It also states that a 4-mm needle is preferred for all injectors regardless of age, sex, ethnicity, or body mass index (BMI) [Cengiz, 2024].

What should I advise about insulin injection sites?

Advise the person:

  • To choose a body area that has plenty of subcutaneous fat, ensuring that the site and hands are clean. The main injection sites are:
    • Abdomen — quick absorption rate (about 15 minutes) compared with other sites.
    • Lateral aspect of arm — intermediate absorption rate (about 20 minutes).
    • Front of thigh/lateral thigh — slow absorption rate (about 30 minutes).
    • Lateral upper quadrant of buttocks — slow absorption rate (about 30 minutes). This site may be useful in small children.
  • That, if necessary, the skin should be 'pinched up' to avoid injecting into the muscle. This is recommended especially for slim people, for injection sites that have little subcutaneous fat, and when using long needles. Pinching up may not be necessary:
    • When using a very short needle (for example, 4 mm needle).
    • If the buttocks are used, due to the abundance of subcutaneous fat.
  • That injection sites should be:
    • Checked by the person regularly for lipohypertrophy (fatty subcutaneous lumps) and cutaneous amyloidosis (rare) due to repeated injection into the same area of skin, and other injection site problems.
    • Reviewed at least annually, and if there are new problems with blood glucose control.
    • Rotated — continuous rotation of the injection site is recommended to reduce the risk of lipohypertrophy. There is a potential risk of delayed insulin absorption and worsened blood sugar control if insulin is injected into sites with lipohypertrophy.
      • The person should alternate between the left and right side of the body on a weekly basis.
      • Injection sites can be rotated within the same body area. Each injection should be at least 1 cm (approximate width of an adult finger) away from the site of the previous injection.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024], and expert opinion in the British National Formulary (BNF) [BNF, 2025].

  • The ISPAD clinical practice consensus guidelines state that lipohypertrophy is an accumulation of subcutaneous fat in response to the adipogenic actions of insulin at a site of multiple injections  [Cengiz, 2024].

What should I advise about insulin storage?

Advise the person that:

  • Insulin that is not currently being used should be stored in a refrigerator at 2–8°C.
    • The person should keep at least one spare insulin vial or cartridge of each type of prescribed insulin.
  • Insulin must not become frozen, and it should be discarded if this occurs.
    • Vials or pens should not be stored in, or too near to, the freezer section or cooling element of the refrigerator.
  • They should check the manufacturer's patient information leaflet (PIL) for specific storage information.
    • Once in use, in general, insulin can be stored at room temperature (below 25–30°C) for 28 days (some insulins may be stable for longer).
    • Insulin must be protected from sunlight and excessive heat (for example, it should not be placed near a cooker, on top of electrical equipment, or left in a car during hot weather).

Basis for recommendation

These recommendations are largely based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024].

What should I advise about blood glucose monitoring?

  • Monitoring of blood glucose involves the use of a handheld meter and provides a measurement of capillary plasma glucose. See the section on Accessories for insulin therapy for more information.
  • Blood glucose self-monitoring skills should be taught at the time of diagnosis and on the initiation of insulin therapy, and should be reviewed at least annually. The review should include checking that the person knows:
    • How to use their blood glucose monitoring meter — this can be done by asking them to demonstrate their technique.
    • When to test — for example before meals and snacks; before bedtime; during periods of illness; before and after exercise; before critical tasks such as driving; and if they feel symptoms of hypoglycaemia.
    • How to interpret and respond to test results, including how to:
      • Interpret trends in blood glucose levels as well as individual readings — this is important for adjusting insulin doses.
      • Identify the causes of high and low blood glucose values.
    • See the sections on Adult blood glucose monitoring and Child and young people blood glucose monitoring for more information on specific targets.
  • A continuous glucose monitoring (CGM) device measures interstitial glucose to provide an estimate of plasma glucose.
    • CGM uses a continuously worn device that measures blood glucose levels and sends the readings to a display device or smartphone. CGM is either real-time CGM (rtCGM) or intermittently scanned CGM (isCGM, commonly referred to as 'flash').
      • CGM should be provided, monitored, and reviewed by a team with expertise in its use to support the person to self-manage diabetes.
      • The choice of CGM device will vary depending on individual preferences, needs, characteristics including age and dexterity, compatibility with other technology, and the functionality of the device, such as whether it provides predictive alerts or alarms indicating when a specific glucose level is reached or trends in glucose levels, that can be shared with a parent or carer.
      • CGM can provide both retrospective and real-time information to detect hypoglycaemic and hyperglycaemic episodes, predict impending hypoglycaemia, and detect wide fluctuations in glucose levels.
  • Every person with type 1 diabetes should have the equipment to undertake capillary blood glucose monitoring, regardless of whether they are using CGM.

Adult blood glucose monitoring

  • Offer adults with type 1 diabetes a choice of real-time continuous glucose monitoring (rtCGM) or intermittently scanned CGM (isCGM). If the person cannot use or does not want rtCGM or isCGM, offer capillary blood glucose monitoring.
  • Advise adults with type 1 diabetes who are using CGM that they will still need to take capillary blood glucose measurements:
    • To check the accuracy of their CGM device.
    • As a back-up (for example, if their blood glucose levels are changing quickly or if the device stops working).
  • Advise adults with type 1 diabetes who are using capillary blood glucose monitoring, to routinely self-monitor blood glucose levels at least 4 times a day (including before each meal and before bed).
  • Advise adults with type 1 diabetes to aim for a:
    • Fasting plasma glucose level of 5–7 mmol/L on waking.
    • Plasma glucose level of 4–7 mmol/L before meals, at other times of the day.
    • Plasma glucose level of 5–9 mmol/L at least 90 minutes after eating (if testing after meals).
  • Advise that bedtime target blood glucose monitoring levels should:
    • Take into account the timing of the last meal and its related insulin dose.
    • Be consistent with the recommended fasting blood glucose level on waking.
  • Advise the person to be particularly careful to avoid hypoglycaemia when driving. See the section on Advice on driving for more information.

Child and young people blood glucose monitoring

  • Offer real-time continuous glucose monitoring (rtCGM) to all children and young people with type 1 diabetes with appropriate education to support the child and/or relatives/carers.
  • Offer intermittently scanned continuous glucose monitoring (isCGM)) to children and young people with type 1 diabetes aged 4 years and over who are unable to use rtCGM or who prefer this method of monitoring.
  • Advise children and young people with type 1 diabetes who are using CGM that they will still need to take capillary blood glucose measurements:
    • To check the accuracy of their CGM device.
    • As a back-up (for example, if their blood glucose levels are changing quickly or if the device stops working).
  • If the child or young person cannot use or does not want rtCGM or isCGM, offer capillary blood glucose monitoring instead.
  • Advise children and young people with type 1 diabetes who are using capillary blood glucose monitoring to routinely self-monitor blood glucose levels at least 5 times a day.
    • More frequent monitoring may be needed if, for example: 
      • The target HbA1c level is not achieved. See the CKS topic on Diabetes - type 1 for more information on target HbA1c levels.
      • The frequency of hypoglycaemic episodes increases, or a person has impaired awareness of hypoglycaemia.
      • There is a legal requirement to do so, such as before driving (for young people of driving age).
      • During periods of intercurrent illness and 'sick day rules'. See the CKS topic on Diabetes - type 1 for more information.
      • With increased physical activity, exercise, and sport.
  • Ensure the child and/or family/carers are aware of the optimal targets for blood glucose monitoring: 
    • Fasting plasma glucose level of 4–7 mmol/L on waking.
    • Plasma glucose level of 4–7 mmol/L before meals at other times of the day.
    • Blood glucose level of 5–9 mmol/L after meals.
  • Advise that maintaining blood glucose levels at the lower end of the target ranges will help to achieve the lowest possible HbA1c.
  • Advise the young person to be particularly careful to avoid hypoglycaemia when driving (if of driving age). See the section on Advice on driving for more information.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024 Diabetes technologies: glucose monitoring  [Tauschmann, 2024], and expert opinion in review articles [Edelman, 2018; Ajjan, 2019].

  • The ISPAD consensus guidelines state that the frequency of blood glucose testing correlates with improved HbA1c levels and reduced rates of acute complications in children and adolescents with type 1 diabetes [Tauschmann, 2024].
  • The NICE committee agreed that there was enough evidence in key outcomes, such as decrease in HbA1c, increased time in range, and reduced severe or nocturnal hypoglycaemia, to demonstrate that both real-time continuous glucose monitoring (rtCGM) and intermittently scanned CGM (isCGM) provide clinical benefits over standard self-monitoring of blood glucose. It cited evidence that increased blood glucose monitoring (up to 4 times a day) was associated with substantial improvements in blood glucose control, but beyond this, the increments in the clinical benefits gained were smaller with higher frequencies of blood glucose testing above 4 times a day. The NICE guidelines recommended targets for blood glucose levels on waking should be higher than other fasting values through the day, in order to reduce the risk of nocturnal hypoglycaemia [NICE, 2023; NICE, 2024].
  • This is supported by the ISPAD consensus guidelines, which note increased evidence in the literature about the benefits of CGM for decreasing diabetic ketoacidosis, decreasing severe hypoglycaemic events, and improving quality of life in children and adolescents with type 1 diabetes [Tauschmann, 2024].
  • The NICE committee noted that the clinical benefits of isCGM for adults were not found in children and young people with type 1 diabetes. Its experience was that the intermittent nature of isCGM can affect adherence in children and young people with type 1 diabetes compared with use of rtCGM, and it therefore recommended that use of isCGM is restricted to certain groups of children and young people [NICE, 2023].
  • The ADA/EASD consensus report states that CGM is preferred in adults, but all adults should learn to perform self-monitoring of blood glucose for back-up and monitoring if CGM is unavailable or not wanted [Holt, 2021].

What are the causes and symptoms of hypoglycaemia?

  • Hypoglycaemia is the main limiting factor in the blood glucose management of type 1 diabetes, and is generally accepted to correspond to a glucose level less than 3.9 mmol/L.
    • It is detected by self-monitoring of blood glucose. The absolute blood glucose level at which signs and symptoms of hypoglycaemia begin to occur can vary.
  • The severity of hypoglycaemia is defined by clinical features:
    • Blood glucose level 3–3.9 mmol/L — represents an alert value for hypoglycaemia.
    • Blood glucose below 3.0 mmol/L — represents clinically important hypoglycaemia which may present with hunger, shakiness, pallor, sweating, palpitations, headache, blurred vision, slurred speech, confusion, dizziness, behavioural change such as irritability and agitation, drowsiness, seizure, loss of consciousness, and coma.
    • 'Severe hypoglycaemia' — describes an event with severe cognitive impairment (including coma and convulsions) requiring assistance and intervention by another person to administer carbohydrates, glucagon, or intravenous glucose for recovery.
  • Problematic or disabling hypoglycaemia may be defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life.
  • Ensure that people on insulin therapy and/or family/carers are given appropriate information on hypoglycaemia, including information on:
  • If hypoglycaemia becomes problematic or increases in frequency, assess for possible contributory causes or risk factors to prevent further episodes, such as:
    • Excessive insulin dose — including inappropriate insulin regimens, incorrect dose distributions, and/or types of insulin. Consider reviewing the current insulin regimen or arrange referral to the diabetes specialist team.
    • Lifestyle issues — including missed meals and reduced food intake, exercise and physical activity, alcohol intake, smoking and substance misuse. Advise that hypoglycaemia can occur several hours after prolonged exercise, or can occur after alcohol ingestion while sleeping. See the CKS topic on Diabetes - type 1 for more detailed information about lifestyle issues.
    • Injection technique and skills.
    • Injection site problems.
    • Difficulties with self-monitoring of blood glucose.
    • Lack of appropriate knowledge and skills for diabetes self-management.
    • Prolonged duration of diabetes and associated increased likelihood of impaired awareness of hypoglycaemia.
    • Changes in insulin sensitivity — including drugs affecting the renin-angiotensin system and kidney disease; puberty increases insulin resistance.
    • Other drug interactions — some drugs can enhance the hypoglycaemic effects of insulin.
    • Physical comorbidities —  conditions such as hypothyroidism, coeliac disease, Addison's disease, gastroparesis (may cause unpredictable rates of food absorption), and chronic kidney disease may contribute to unpredictable blood glucose control.
    • Mental health and psychosocial issues — conditions such as anxiety, depression, eating disorders, behavioural and conduct disorders, learning disability, relationship problems, and inadequate social support can affect a person's knowledge and skills for diabetes self-management. Consider referring the person for additional professional support, as needed.
  • For adults with recurrent episodes of hypoglycaemia, consider referral to the diabetes specialist team for a review of their current insulin regimen.
  • If there are symptoms of nocturnal hypoglycaemia (such as lethargy, altered mood, or headache on waking) or if this is detected on blood glucose self-monitoring:
    • Review the person's knowledge and skills for diabetes self-management.
    • Review the person's current insulin regimen, evening eating habits, and physical activity levels.
    • Advise the person to:
      • Check their blood glucose levels overnight, for example between 2 am and 3 am, when hypoglycaemia is most likely to happen.
      • Eat a carbohydrate snack before bedtime and keep a source of fast-acting carbohydrate next to the bed.
    • Consider referral to the diabetes specialist team for a review of their current insulin regimen if needed.

Managing acute hypoglycaemia

  • Advise that people with acute hypoglycaemia who are able to swallow should:
    • Promptly consume 10–20 g of a fast-acting form of carbohydrate, preferably in liquid form as this is easier to take. It may be necessary to give the carbohydrate in small amounts as hypoglycaemia may cause vomiting.
      • As a guide for children and young people, approximately 0.3 g/kg of fast-acting carbohydrate should be given.
      • In general, 10–20 g of fast-acting carbohydrate corresponds to 3–6 glucose tablets; 90–180 mL of fizzy drink or squash (not sugar-free or reduced-sugar versions); 50–100 mL of Lucozade Energy® (contains 26% glucose syrup per 100 mL); 2–4 spoonfuls of sugar added to a cup of drink (for example water); sweets, such as four large jelly babies or seven large jelly beans; and 1–2 two tubes of Dextrogel® (contains 10 g of glucose and is available on prescription or can be purchased over-the-counter).
      • Advise to avoid chocolates and biscuits as the initial treatment of hypoglycaemia, as the high fat content may delay intestinal absorption of glucose.
    • Recheck capillary blood glucose levels within 15 minutes.
      • Advise that fast-acting glucose should raise blood glucose levels within 5–15 minutes.
      • If there is no response or an inadequate response, continue to give more fast-acting glucose, and re-test capillary blood glucose levels every 15 minutes until the blood glucose level improves.
      • Advise that improvements in signs and symptoms may lag behind improvements in blood glucose level.
    • After the acute symptoms have resolved or the capillary blood glucose level increases to above 3.9 mmol/L:
      • Advise the person to eat 20 g of complex long-acting carbohydrate (such as bread, milk, biscuits, or fruit) as part of a snack or meal to maintain the blood glucose level. This is not necessary for people on an insulin pump.
  • If the person has a reduced level of consciousness and is unable to swallow (severe hypoglycaemia):
    • Administer intramuscular (IM) glucagon immediately.
      • For children below 8 years of age (or body weight less than 25 kg), give 500 micrograms of glucagon.
      • For children and adults with a body weight of more than 25 kg, give 1 mg of glucagon.
      • Note: the person's relatives/carers should be trained and equipped to give IM glucagon for severe hypoglycaemia in an emergency, if clinically appropriate.
    • Arrange emergency transfer to hospital by calling 999 if:
      • IM glucagon is not available.
      • The family/carers are not trained to administer glucagon.
      • Alcohol is the cause of, or has contributed to, the development of hypoglycaemia — IM glucagon may be ineffective and intravenous (IV) glucose may be needed.
    • If the person does not respond to IM glucagon treatment within 10 minutes, arrange emergency transfer to hospital by calling 999 — treatment with IV glucose may be needed.
    • If the person responds to IM glucagon treatment within 10 minutes and is sufficiently awake and able to swallow safely, give additional oral carbohydrate and ensure the person is monitored closely to check for recurrent hypoglycaemia.
      • Vomiting is common in the recovery phase, and recurrent hypoglycaemia may occur. Consequently, the person should have close monitoring of blood glucose levels. See the section on Self-monitoring of blood glucose for more information.
      • If hypoglycaemia recurs, the person may require additional oral carbohydrate or emergency transfer to hospital by calling 999 — treatment with IV glucose may be needed if symptoms are severe.

Managing impaired hypoglycaemia awareness

Impaired awareness of hypoglycaemia describes the reduced or absent ability to recognize the symptoms of low blood glucose levels that would otherwise prompt an appropriate corrective intervention.

  • Assess hypoglycaemia awareness in adults with type 1 diabetes at each annual review.
  • Offer management of impaired awareness of hypoglycaemia to the person and/or family/carers:
    • Ensure that adults with type 1 diabetes and impaired hypoglycaemia awareness have had structured education in flexible insulin therapy using basal-bolus regimens, and are following its principles correctly. See the section on Adult insulin regimens for more information.
    • Offer additional education, focusing on avoiding and treating hypoglycaemia if the person continues to have impaired awareness of hypoglycaemia. See the CKS topic on Diabetes - Type 1 for more information on patient education.
    • Explain that impaired awareness of the symptoms of blood glucose levels below 3 mmol/L is associated with a significantly increased risk of severe hypoglycaemia.
    • Review the person's insulin regimen and doses. If the target blood glucose levels are lower than recommended, reinforce the recommended treatment targets. See the section on Self-monitoring of blood glucose for more information.
    • Avoid relaxing individualized blood glucose targets as a treatment for impaired awareness of hypoglycaemia.
  • Offer or refer to the diabetes specialist team for consideration of an insulin pump or real-time continuous glucose monitoring if:
    • The person continues to have impaired awareness of hypoglycaemia.
    • Impaired awareness of hypoglycaemia is associated with recurrent severe hypoglycaemia despite these interventions.
  • Further information on What is hypo anxiety? is available on the Diabetes UK website (www.diabetes.org.uk). 

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024], Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], and the NICE Technology Appraisal guidance Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus [NICE, 2008], the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes [Abraham, 2022], and expert opinion in the British National Formulary (BNF) [BNF, 2025].

The causes and symptoms of hypoglycaemia
  • The ISPAD clinical practice consensus guidelines recommend that a blood glucose value less than 3.9 mmol/L is used as the 'clinical alert' or 'threshold value' for starting treatment for hypoglycaemia, due to the potential for blood glucose to fall further, and to avoid consequences of a glucose level falling below 3.0 mmol/L. It states a blood glucose level below 3.0 mmol/L is defined as 'clinically important', as neurogenic symptoms and cognitive dysfunction can occur below this threshold [Abraham, 2022]. These recommendations are supported by the ADA/EASD consensus report [Holt, 2021].
  • The definition of 'problematic or disabling hypoglycaemia' is based on the NICE Technology Appraisal guidance [NICE, 2008].
  • The ISPAD clinical practice consensus guidelines state that hypoglycaemia and fear of hypoglycaemia are significant physiological and psychological barriers to achieving optimal blood glucose control, and may cause emotional issues for children with type 1 diabetes and their relatives/carers. They also note that monitoring for hypoglycaemia is a key component of diabetes care, together with education about its causes, prevention, and treatment [Abraham, 2022].
  • The information about possible contributory causes or risk factors for hypoglycaemia is based on the ADA/EASD consensus report [Holt, 2021], the ISPAD clinical practice consensus guidelines [Abraham, 2022], and is also extrapolated from the NICE guideline on type 1 diabetes in adults [NICE, 2024].
  • The recommendation to arrange referral to the diabetes specialist team if there is recurrent hypoglycaemia is extrapolated from the ADA/EASD consensus report, which states that 'structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioural therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, are effective treatments'. In addition, there is some evidence that continuous glucose monitoring (CGM) use can help identification of current or impending low blood glucose levels that a person may not have awareness of [Holt, 2021].
  • The recommendations about management of nocturnal hypoglycaemia are based on the NICE guideline on type 1 diabetes in adults [NICE, 2024] and the ISPAD clinical practice consensus guidelines [Abraham, 2022].
  • The ISPAD clinical practice consensus guidelines note that impaired hypoglycemia awareness increases the risk of severe hypoglycaemia. In addition, factors such as younger age, lower HbA1c levels, prior exercise, and hypoglycaemia are associated with an increased risk for nocturnal hypoglycaemia  [Abraham, 2022].
Managing acute hypoglycaemia
  • The recommendations about the management of acute hypoglycaemia are largely based on the NICE guidelines [NICE, 2023; NICE, 2024] and the ISPAD clinical practice consensus guidelines [Abraham, 2022], together with the ADA/EASD consensus report, which notes that 'correction of hypoglycaemia is the oral intake of approximately 15 g of glucose or equivalent simple carbohydrate when a capillary blood glucose level is less than 3.9 mmol/L' [Holt, 2021].
  • The ISPAD clinical practice consensus guidelines state that glucose-containing products are recommended for immediate treatment because of their rapid absorption from the intestine [Abraham, 2022].
  • The ADA/EASD consensus report notes that there may be a 5–15 minute lag between changes in capillary blood glucose and interstitial glucose readings detected by CGM, so the restoration of normal blood glucose levels may not be detected by CGM straight away. The use of capillary glucose measurement is therefore recommended to prevent over-treatment of the hypoglycaemia [Holt, 2021].
  • The recommendations about treatment of severe hypoglycaemia with a reduced level of consciousness with intramuscular (IM) glucagon is based on the fact oral glucose intake is contraindicated due to the risk for aspiration [Holt, 2021].
  • The recommendations about when to arrange emergency transfer to hospital are extrapolated from the NICE guidelines [NICE, 2023; NICE, 2024].
Managing impaired hypoglycaemia awareness
  • These recommendations are largely based on the NICE guideline on type 1 diabetes in adults [NICE, 2024], together with the ADA/EASD consensus report [Holt, 2021] and the ISPAD clinical practice consensus guidelines, which note that impaired hypoglycemia awareness can occur in children with diabetes and is associated with a significantly increased risk of severe hypoglycaemia [Abraham, 2022].

How should I manage injection site problems?

Advise to check injection sites regularly to assess for problems:

  • Painful injections
    • Advise the person to numb the area (for example by rubbing with a piece of ice) for 15–20 seconds before injecting.
    • Ensure that insulin is not used straight from the refrigerator — cold insulin can make injection painful.
    • Ensure that the person uses a new sharp needle for every injection — reused needles can cause more pain.
    • Consider changing the length of the needles — a shorter needle may be less painful.
    • Review the person's injection technique and check the angle and depth of injection — ensure that insulin is injected with the needle at a 90° angle to the skin surface and that injection is subcutaneous not intramuscular.
  • Bleeding and bruising
    • Reassure the person that bleeding may occasionally occur when the needle is withdrawn.
    • Advise the person to gently apply pressure to the site for a couple of minutes to minimize bruising.
    • Review the injection technique — bruising and bleeding can occur if the insulin is accidentally injected intramuscularly (instead of subcutaneously) or with tight squeezing of the skin.
    • Consider changing the length of the needle — a shorter needle may reduce the risk of injecting insulin intramuscularly.
  • Redness, swelling, and itching at the injection site
    • Reassure the person that local reactions usually resolve after a few days (to several weeks).
    • Consider referring the person to the diabetes specialist team to consider switching to an insulin analogue if local reactions with human insulin are problematic and persist for longer than 2–4 weeks.
    • Exclude other causes for symptoms, such as a reaction to soap or cosmetics, poor injection technique, or reaction to the preservatives, pH, or additives in the insulin preparations or insulin pump adhesives (which may require a change of insulin preparation). Information on each product's excipients including preservatives can be found in the manufacturers' Summary of Product Characteristics (see www.medicines.org.uk for more information).
  • Lipohypertrophy
    • Explain that this is caused by repeatedly injecting the same small area, resulting in a buildup of subcutaneous fatty lumps. This can cause erratic or delayed absorption of insulin, and can be unsightly.
    • Offer reassurance that this can be minimized by rotating injection sites.
    • Advise the person not to inject insulin into affected areas — they should wait until the affected area has become soft before reusing it.
    • Explain that depending on the severity of lipohypertrophy, the area may take some time to recover (from weeks to several months or longer). Lipoatrophy (localized loss of fat tissue) can rarely occur with human insulin and insulin analogues.
  • Insulin leakage
    • Advise the person to leave the needle in the skin for 15 seconds (or longer for large doses) to ensure that the entire dose is injected.
    • Advise slower withdrawal of the needle from the skin, stretching of the skin after the needle is withdrawn, or pressure with a clean finger over the injection site may minimize insulin leakage.
    • Advise not to inject a second insulin dose to compensate for the leaked insulin.
    • Review the person's injection technique if leakage occurs often, and consider the need for needles of different lengths.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024]. They are also pragmatic, based on what CKS considers to be good clinical practice.

  • The ISPAD clinical practice consensus guidelines state that lipohypertrophy is an accumulation of subcutaneous fat in response to the adipogenic actions of insulin at a site of multiple injections. Reduction of lipohypertrophy improves blood glucose control [Cengiz, 2024].

How should I manage other adverse effects of insulin therapy?

Other possible adverse effects of insulin therapy include:

  • Altered vision (uncommon) — on initiation of insulin treatment, refraction disorders and altered vision may occur if blood glucose levels change markedly.
    • Reassure the person that this is usually temporary. Advise the person to avoid changing their glasses until their blood glucose levels have stabilized.
  • Acute painful neuropathy — this may occur if there is rapid improvement in blood glucose control.
    • Reassure the person that this is a self-limiting condition and that symptoms improve over time.
    • Advise on the use of simple analgesia (paracetamol and/or a nonsteroidal anti-inflammatory drug if indicated) first-line for symptom relief.
    • If simple analgesia is ineffective, consider the use of additional treatment(s) for neuropathic pain. See the CKS topic on Neuropathic pain - drug treatment for more information.
  • Insulin oedema (rare) — this may occur on initiation or intensification of insulin therapy, particularly in people with a low body mass index (BMI) or suboptimally controlled diabetes.
    • Reassure the person that symptoms should resolve within 3–4 days after reduction of the insulin dose. Seek management advice from the diabetes specialist team if clinically indicated.
    • If oedema persists, consider other causes for symptoms, using clinical judgement.

Basis for recommendation

This information is based on the National Institute for Health and Care Excellence (NICE) guideline Type 1 diabetes in adults: diagnosis and management [NICE, 2024], and expert opinion in a review article on insulin oedema [Amrapala, 2019] and in the British National Formulary (BNF) [BNF, 2025]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Which drug interactions are associated with insulin?

  • Drugs that can enhance the hypoglycaemic effects of insulin (and hence reduce insulin requirement) include:
    • Alcohol — signs of hypoglycaemia may be less obvious following alcohol intake, and delayed hypoglycaemia may occur (hours after alcohol consumption). Further information on Alcohol and diabetes is available on the Diabetes UK website (www.diabetes.org.uk). Advise to always wear or carry some form of diabetes identification, as the reduced awareness of hypoglycaemia may be confused with alcohol intoxication.
    • Anabolic steroids.
    • Angiotensin-converting enzyme (ACE) inhibitors.
    • Beta-blockers — may also mask the warning signs of hypoglycaemia (such as tremor).
    • Fibrates.
    • Monoamine oxidase inhibitors.
    • Salicylates.
    • Sulphonamides.
    • Other anti-diabetic medications.
  • Drugs that can antagonize the hypoglycaemic effects of insulin (and hence increase insulin requirements) include:
    • Corticosteroids.
    • Danazol.
    • Diuretics (loop and thiazide).
    • Glucagon.
    • Growth hormone.
    • Levothyroxine.
    • Oral contraceptives.
    • Sympathomimetic drugs (such as adrenaline, salbutamol, and terbutaline).

Basis for recommendation

This information is based on expert opinion in the British National Formulary (BNF) [BNF, 2025] and an international encylopedia of adverse drug reactions and interactions [Aronson, 2016].

What safety issues are important when using insulin therapy?

  • Advise people prescribed insulin therapy that:
    • They should only use devices that have been recommended or prescribed by the diabetes specialist team.
      • They should not stop or change their prescribed insulin regimen without seeking the advice of the diabetes specialist team.
      • If they are contacted directly by a manufacturer or other organisation to try using a different insulin therapy system, they should first discuss this with their diabetes specialist to avoid risk of hyperglycaemia, hypoglycaemia, or diabetic ketoacidosis.
    • They should not use insulin syringes and needles to extract insulin directly from pen devices or refill cartridges.
      • Insulin syringes have graduations only suitable for calculating doses of standard 100 units/mL. If insulin extracted from a pen or cartridge is of a higher strength and is not considered in determining the volume required, it can lead to a significant and potentially fatal overdose.
      • If the person is unable to use their pen device as normal, they should contact their diabetes specialist team for urgent advice.
    • They should always wear or carry some form of identification indicating that they have diabetes, such as a MedicAlert® bracelet, necklace, or watch (available from www.medicalert.org.uk) and/or the Diabetes ID Card (available from www.diabetes.co.uk). Adults on insulin therapy should also be given a patient information booklet and an Insulin Passport.
  • Ensure that people prescribed insulin therapy are:
    • Given information about awareness and management of hypoglycaemia. See the section on Hypoglycaemia for more information.
    • Aware of the need to notify the Driver and Vehicle Licensing Agency (DVLA) if they drive. See the section on Driving for more information.
    • Given appropriate information on how to manage diabetes during a period of intercurrent illness ('sick-day rules'). See the CKS topic on Diabetes - type 1 for more detailed information.

Basis for recommendation

  • The recommendation to only use devices that have been recommended or prescribed by the diabetes specialist team is based on a Medical Device Alert published by the Medicines and Healthcare products Regulatory Agency (MHRA) [MHRA, 2016].
  • The recommendation not to use insulin syringes and needles to extract insulin directly from pen devices or refill cartridges and the associated risk of severe harm or death is based on an NHS Improvement Patient Safety Alert Risk of severe harm and death due to withdrawing insulin from pen devices [NHS Improvement, 2016].
  • The recommendation to wear or carry a form of diabetes identification is based on the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes [Abraham, 2022], and expert opinion in the British National Formulary (BNF) [BNF, 2025].

What should I advise about lifestyle and cultural issues?

Driving

  • Remind drivers with type 1 diabetes of the need to be particularly careful to avoid hypoglycaemia.
    • They should:
      • Have a supply of a fast-acting carbohydrate in the vehicle and avoid driving if their meal is delayed.
      • Have a blood glucose level of at least 5 mmol/L before they start a journey.
      • Check their blood glucose level just before they start the journey and then every 2 hours during the journey. If the blood glucose level is low, they should stop the car in a safe place, switch off the engine and move from the driver's seat; eat or drink a fast-acting carbohydrate, then wait until 45 minutes after the blood glucose has returned to normal before continuing the journey.
      • Take regular meals, snacks, and rest periods on long journeys, and always avoid alcohol.
      • Take particular care during changes of insulin regimens, changes of lifestyle, exercise and physical activity, and travel.
    • Advise drivers with diabetes to always wear or carry some form of diabetes identification to show that they have diabetes in case of injury in a road traffic collision.
  • Advise people with diabetes that it is the responsibility of the driving licence holder or applicant to notify the Driver and Vehicle Licensing Agency (DVLA) of their medical condition. 
    • Drivers can be fined up to £1000 if they do not tell the DVLA about a medical condition that affects their driving. They may be prosecuted if they are involved in a road traffic collision as a result. Information on how to report the condition is available on the section Diabetes and driving of the DVLA website.
    • Once the condition is reported, the DVLA will send out a detailed letter explaining the licensing and driving requirements and responsibilities. 
  • For detailed information on Group 1 and 2 entitlements, see the DVLA publication Assessing fitness to drive: a guide for medical professionals.
  • Further information on Driving and diabetes and Diabetes and your driving licence is available on the Diabetes UK website (www.diabetes.org.uk). 

Fasting including Ramadan

Fasting for religious and cultural reasons is a widespread practice globally. Various groups, including pre-pubertal children, the elderly, and people with a chronic medical condition (including diabetes), where fasting is detrimental to health, are exempt from fasting for religious reasons such as Ramadan.

  • Children and young people with type 1 diabetes are strongly advised not to fast due to the high risk of acute complications such as hypoglycaemia or diabetic ketoacidosis resulting from uncontrolled post-prandial hyperglycaemia. See the CKS topic on Diabetes - type 1 for more information about diabetic ketoacidosis.
  • Offer people with type 1 diabetes and relatives and/or carers pre-fasting diabetes education and counselling about the issues associated with fasting and feasting.
    • Pre-fasting education should cover insulin type and action, insulin dose adjustment, optimizing blood glucose before fasting, blood glucose monitoring, nutrition, physical activity, sick days, and the recognition and treatment of hyperglycaemia and hypoglycaemia.
      • Seek specialist advice or refer to the diabetes specialist team if the person is unsure how to adjust their insulin therapy during the fasting period.
    • Pre-fasting counselling should cover the need for capillary blood glucose self-monitoring or insulin injection during fasting to prevent acute complications. The presence of impaired awareness of hypoglycaemia needs to be excluded pre-fasting.
  • If the person is committed to fasting, give appropriate advice to the person and/or relatives/carers.
    • The person needs to have good hypoglycaemia awareness during fasting, and this needs to be monitored during fasting. Break the fast immediately, regardless of the timing, if there is hypoglycaemia.
    • Check blood glucose levels regularly with frequent self-monitoring of blood glucose or continuous glucose monitoring (CGM) during fasting, to minimize the risk of hypoglycaemia and detect periods of hyperglycaemia. See the section on Blood glucose monitoring for more information.
      • Reassure the person that self-monitoring of blood glucose by pricking the skin does not break the fast.
    • Give nutrition advice including recommended foods offered after breaking the fast, to prevent acute complications, excessive weight gain, and adverse changes in lipid profile. Meals based on low glycaemic index carbohydrates, fruit, vegetables, low-fat dairy products, legumes, whole grains, and lean proteins are recommended; sweets, sweetened drinks, and fried foods should be limited.
    • Maintain hydration by drinking water and other non-sweetened drinks at regular intervals during non-fasting hours.
    • For Ramadan fasting, eat the pre-dawn meal as late as possible before the start of the daily fast.
    • Avoid rigorous exercise or physical activity (particularly during the few hours before the fast-breaking meal) as this can increase the risk of hypoglycaemia. Encourage the person to maintain their usual physical activity (especially during non-fasting periods).
  • Further information on Diabetes and Ramadan is available on the Diabetes UK website (www.diabetes.org.uk).

Employment including shift work

  • Shift work (particularly night shifts) is associated with poorer control of diabetes blood glucose levels, partly due to changes in routine which can affect meal times, medication schedules, and sleep pattern.
  • If a person with type 1 diabetes has to work shifts, ensure they know how to adjust their insulin doses and regimen appropriately.
    • Refer people who are unsure of what to do to the diabetes specialist team, who may have access to structured educational training on insulin dose adjustment for shift workers.
  • Advise the person to:
    • Bring food and snacks from home to work.
    • Prepare or freeze meals beforehand so that they are ready to eat when they get home.
    • Try to eat in line with a regular day, for example, if working an afternoon shift, advise to eat a healthy, filling lunch before the shift starts, rather than in the middle of the shift. If working a night shift, try to eat the main meal before the shift starts at a regular time and have a light snack at break time.
      • If there is any uncertainty, seek advice from the diabetes specialist team about planning eating around shifts, including mealtimes and types of foods.
    • Keep hydrated, keep a bottle of water or sugar-free drink with them, and reduce any caffeinated drinks.
    • Discuss with their employer or an occupational health team if shift work is causing problems with diabetes management. Options may include an altered shift pattern, more regular shift times, or a different role within the organization.
  • Further information on Your lifestyle, diabetes and food and Work and diabetes is available on the Diabetes UK website (www.diabetes.org.uk) and the section on Shift work and diabetes on the Diabetes.co.uk website.

Holidays and travel

  • Offer a person with type 1 diabetes general travel advice, such as:
    • Always carry a form of diabetes identification in case of emergency.
    • Have a supply of a fast-acting carbohydrate to treat a possible episode of hypoglycaemia.
    • Avoid excessive alcohol intake which increases the risk of hypoglycaemia.
    • Obtain appropriate travel insurance.
    • Take necessary precautions if driving.
    • Consider the potential impact of changes in usual schedule, hot weather, dietary changes, reduced or increased stress levels and relaxation, and changes in exercise patterns on glucose levels while travelling.
  • Offer advice on how to manage insulin therapy while travelling:
    • Advise the person to carry appropriate quantities of insulin (including extra back-up insulin) and accessories in their hand luggage (and a spare set on the person in case their luggage is lost or stolen).
    • Advise to adjust their insulin regimens including how to adapt to the time difference, if the time zone change is more than 4 hours.
      • If the person requires more flexibility in their insulin regimen (for example if they are a frequent long-distance traveller or plan to cross many different time zones), seek specialist advice or refer the person to the diabetes specialist team.
  • If necessary, provide documentation or advise to obtain this from the diabetes specialist team, for customs and security measures at the airport. Documentation may also help if the person needs to replace lost/damaged/stolen medication or seek medical attention while travelling, and may include:
    • All prescribed medication.
    • All necessary monitoring and dispensing equipment.
    • The necessity of carrying medication, insulin, needles, syringes, and other accessories in hand luggage.
  • Further information on Travelling with diabetes is available on the Diabetes UK website (www.diabetes.org.uk) and there is a factsheet Diabetes on the TravelHealthPro website (www.travelhealthpro.org.uk).

Insurance

  • Inform a person with type 1 diabetes using insulin therapy that:
    • For car insurance, they must notify the car insurance company immediately and on renewal that they are on insulin therapy.
    • For insurance or assurance for loans and life cover, they must declare the diagnosis of diabetes and any treatment they are taking, including insulin.
    • For travel insurance, they should check that the policy covers type 1 diabetes, as policies may exclude pre-existing medical conditions.
  • Further information on Insurance and diabetes and Life insurance for people with diabetes is available on the Diabetes UK website (www.diabetes.org.uk).

Basis for recommendation

Driving
  • These recommendations are based on the Driver and Vehicle Licensing Agency (DVLA) guide Assessing fitness to drive: a guide for medical professionals [DVLA, 2024], the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], and resources on the Diabetes UK website.
    • The ADA/EASD consensus report notes that 'unrecognized hypoglycaemia and rapidly dropping glucose levels are the most relevant hazards for drivers with type 1 diabetes. These risks may be reduced by the use of continuous glucose monitoring (CGM) or blood glucose monitoring prior to driving and at 2-hourly intervals' [Holt, 2021].
Fasting including Ramadan
  • These recommendations are largely based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2022: Ramadan and other religious fasting by young people with diabetes [Deeb, 2022] and the International Diabetes Federation (IDF) and Diabetes and Ramadan (DaR) International Alliance publication Diabetes and Ramadan: Practical guidelines 2021 [Hassanein, 2022], together with the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023] and resources on the Diabetes UK website.
    • The ISPAD clinical practice consensus guidelines state that 'Ramadan fasting is one of the five pillars of Islam and is obligatory for all healthy adult and adolescent Muslims from the time of completing puberty'. It notes that various population groups are exempted from fasting, such as people who are 'menstruating, pregnant or breastfeeding women, prepubertal children, the elderly, individuals with any acute or chronic illness in whom fasting would be detrimental to health, individuals with an intellectual disability, or individuals who are travelling' [Deeb, 2022].
    • The ISPAD clinical practice consensus guidelines also note that 'pre-fasting assessment and education are vital to ensure the suitability and safety of fasting in young people with diabetes'. Regular supervision and monitoring is needed during periods of fasting to minimize potential risks including hyperglycaemia, hypoglycaemia, ketoacidosis, and dehydration [Deeb, 2022].
    • The recommendation to seek specialist advice if there is uncertainty about how to adjust the person's insulin regimen during periods of fasting is pragmatic, based on what CKS considers to be good clinical practice.
Employment including shift work
  • These recommendations are largely based on resources on the Diabetes UK and the diabetes.co.uk websites.
Holidays and travel
  • These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication ISPAD Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes [Cengiz, 2024], and are also pragmatic, based on what CKS considers to be good clinical practice.
    • The ADA/EASD consensus report states that a plan of adjusting insulin doses, especially when travelling across time zones, is essential to reduce glucose fluctuations. In addition, it recommends to 'consider the impact of change in usual schedule, hot weather, reduced stress and relaxation, and changes in exercise patterns on glucose levels' while on holiday [Holt, 2021].
Insurance
  • These recommendations are based on resources on the Diabetes UK website.

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], and various publications from the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) and the International Society for Pediatric and Adolescent Diabetes (ISPAD). The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on insulin therapy in type 1 diabetes in primary care.

Search dates

June 2020 - March 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 8th June 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S10    S6 AND S9 
S9    S7 OR S8 
S8    AB insulin* OR TI insulin* 
S7    (MH "Insulin+") 
S6    S1 OR S2 OR S3 OR S4 OR S5 
S5    TI "juvenile-onset diabetes" OR TI "juvenile onset diabetes" 
S4    TI IDDM 
S3    TI "insulin-dependent diabetes mellitus" OR TI "insulin dependent diabetes mellitus" 
S2    TI (diabet* n3 "type 1") OR TI (diabet* n3 "type I") 
S1    (MH "Diabetes Mellitus, Type 1+") 

 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Abraham, M.B., Karges, B., Dovc, K., et al. (2022) ISPAD Clinical Practice Consensus Guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatric Diabetes 23(8), 1322-1340. [Abstract]
  • Ajjan, R.,  Slattery, D. and Wright, E. (2019) Continuous glucose monitoring: a brief review for primary care practitioners. Advances in Therapy 36, 579-596. [Free Full-text]
  • Amrapala, A. and Chowdhury, T.A. (2019) Severe oedema in a patient with diabetes. Clinical Medicine 19(4), 325-326. [Abstract]
  • Aronson, J.K. (Eds.) (2016) Insulin. In: Meyler's side effects of drugs. The international encyclopedia of adverse drug reactions and interactions. 16th edn. Elsevier Science, 111-143.
  • BNF (2025) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • Cengiz, E., Danne, T., Ahmad, T., et al. (2024) International Society for Pediatric and Adolescent Diabetes Clinical practice consensus guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes. Hormone Research in Paediatrics 97(6), 584-614. [Abstract]
  • Deeb, A., Babiker, A., Sedaghat, S., et al. (2022) ISPAD Clinical Practice Consensus Guidelines 2022: Ramadan and other religious fasting by young people with diabetes. Pediatric Diabetes 23(8), 1512-1528. [Abstract]
  • DVLA (2024) Assessing fitness to drive: a guide for medical professionals. Driver and Vehicle Licensing Agency. https://www.gov.uk [Free Full-text]
  • Edelman, S.V., Argento, N.B., Pettus, J. and Hirsch, I.B. (2018) Clinical implications of real-time and intermittently scanned continuous glucose monitoring. Diabetes Care 41(11), 2265-2274. [Free Full-text]
  • Hassanein, M., Afandi, B., Ahmedani, M.Y., et al. (2022) Diabetes and Ramadan: Practical guidelines 2021. Diabetes Research and Clinical Practice 185. [Abstract]
  • Holt, R.I.G., DeVries, J.H., Hess-Fischl, A., et al. (2021) The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 64(12), 2609-2652. [Abstract]
  • MHRA (2015) High strength, fixed combination and biosimilar insulin products: minimising the risk of medication error. Medicines and Healthcare products Regulatory Agency. https://www.gov.uk [Free Full-text]
  • MHRA (2016) Managing diabetes: patients should not change their insulin delivery device without checking with their healthcare specialist. Medicines and Healthcare products Regulatory Agency. http://www.gov.uk [Free Full-text]
  • NHS Improvement (2016) Risk of severe harm and death due to withdrawing insulin from pen devices. NHS England and NHS Improvement. http://www.improvement.nhs.uk [Free Full-text]
  • NICE (2008) Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus. Review of technology appraisal guidance 57 (NICE technology appraisal 151). National Institute for Health and Clinical Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2023) Diabetes (type 1 and type 2) in children and young people: diagnosis and management. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2024) Type 1 diabetes in adults: diagnosis and management. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Rahman, M.S., Hossain, K.S., Das, S., et al. (2021) Role of insulin in health and disease: an update. International Journal of Molecular Sciences 22(12). [Abstract]
  • Tauschmann, M., Cardona-Hernandez, R., DeSalvo, D.J., et al. (2024) International Society for Pediatric and Adolescent Diabetes Clinical practice consensus guidelines 2024 Diabetes technologies: glucose monitoring. Hormone Research in Paediatrics 97(6), 615-635. [Abstract]
Change privacy settings