Basis for recommendation

The recommendations on initiating insulin therapy are based on the National Institute for Health and Care Excellence (NICE) clinical guidelines Type 2 diabetes in adults: management [NICE, 2026] 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) clinical practice consensus guidelines Insulin treatment in children and adolescents with diabetes [Cengiz, 2022], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], the American Diabetes Association (ADA) publication Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes - 2024 [Americal Diabetes Association, 2024], and expert opinion in review articles on barriers to insulin therapy [Russell-Jones, 2018; Galdón Sanz-Pastor, 2024].

Insulin therapy in adults

• The recommendations on when to consider initiating insulin therapy in adults are based on the NICE clinical guideline on adults [NICE, 2026], the RCN guideline [RCN, 2022], and the ADA publication [Americal Diabetes Association, 2024].
  • The RCN guideline notes that people who are most likely to  benefit from insulin therapy include those with marked symptoms, who are slim and losing weight, well-motivated, careful with their diet, and have established complications and/or a long life expectancy. The ADA publication recommends the early introduction of insulin if there is evidence of ongoing catabolism (weight loss), symptoms of hyperglycaemia, or persistently raised HbA1c levels, for example.
• The information on possible barriers to starting insulin therapy is based on the RCN guideline [RCN, 2022]. In addition, expert opinion in a review article notes that there may be 'clinical or therapeutic inertia' in intensifying diabetes treatment regimens, causing delays in insulin initiation, dose adjustment, and intensification, and an increased risk of diabetes-related complications [Russell-Jones, 2018]. This and an additional review highlight possible reasons for non-initiation of insulin including concerns about weight gain, hypoglycaemia, and adverse effects, fear of injections and self-monitoring blood glucose, concerns about impact on daily life, and comorbid mental health conditions such as anxiety and depression [Russell-Jones, 2018; Galdón Sanz-Pastor, 2024].

Insulin therapy in children

• The information about insulin therapy in children and young people derives from the NICE clinical guideline [NICE, 2023].
• The ISPAD guidelines note the need for appropriate education and discussion about insulin therapy to be based on the age, maturity, and individual needs of the child/family [Cengiz, 2022].

Basis for recommendation

The recommendations on self-monitoring of blood glucose are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Type 2 diabetes in adults: management [NICE, 2022a], the joint American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report Management of hyperglycemia in type 2 diabetes [Davies, 2022], and the International Society for Pediatric and Adolescent Diabetes (ISPAD) clinical practice consensus guidelines Glycemic control targets and glucose monitoring for children, adolescents, and young adults with diabetes [de Bock, 2022].

Basis for recommendation

The information on insulin products is based on the National Institute for Health and Care Excellence (NICE) clinical guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the National Institute for Health and Care Excellence (NICE) clinical guideline Type 2 diabetes in adults: management [NICE, 2026], the joint American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report Management of hyperglycemia in type 2 diabetes, [Davies, 2022], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], the International Society for Pediatric and Adolescent Diabetes (ISPAD) clinical practice consensus guidelines Insulin treatment in children and adolescents with diabetes [Cengiz, 2022], 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].

• The MHRA drug safety update notes that high-strength insulin products such as Tresiba^® and Toujeo^® have been developed for people with large daily insulin requirements to reduce the number and volume of injections, however it is important for healthcare professionals and patients to understand the insulin strength of these different products, so that the risk of medication and dose errors is minimized [MHRA, 2015].

Insulin regimen options

• Provide a structured education programme to adults with type 2 diabetes starting insulin therapy. The programme should include:
  • Injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites
  • Self-monitoring
  • Dose titration to target levels
  • Dietary advice
  • The DVLA's Assessing fitness to drive: a guide for medical professionals
  • Managing hypoglycaemia
  • Managing acute changes in plasma glucose
  • Support from a healthcare professional trained in insulin therapy

• When initiating insulin for adults with type 2 diabetes:
  • Continue to offer metformin to people already taking it
  • Stop any other medicines being used solely to manage hyperglycaemia
  • Discuss with the person the risks and benefits of continuing medicines for other benefits such as cardiovascular protection or weight management
  • The choice of insulin therapy regimen should be individualized, and will vary depending on the person's age, duration of diabetes, lifestyle, treatment targets, risk of hypoglycaemia and other adverse effects, and patient preference.

Basis for recommendation

The information on insulin regimens is based on the National Institute for Health and Care Excellence (NICE) clinical guideline Type 2 diabetes in adults: management [NICE, 2026], the International Society for Pediatric and Adolescent Diabetes (ISPAD) clinical practice consensus guidelines Insulin treatment in children and adolescents with diabetes [Cengiz, 2022], the joint American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report Management of hyperglycemia in type 2 diabetes [Davies, 2022], and the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022].

• The ISPAD clinical practice consensus guidelines emphasize the importance of an individualized insulin therapy regimen, which optimizes glycaemic control and reduces complications from diabetes [Cengiz, 2022].

Basis for recommendation

The information on accessories for insulin therapy is largely based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) clinical practice consensus guidelines Insulin treatment in children and adolescents with diabetes [Cengiz, 2022] and Exercise in children and adolescents with diabetes [Adolfsson, 2022], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], the Medicines and Healthcare products Regulatory Agency (MHRA) device safety information Managing diabetes: patients should not change their insulin delivery device without checking with their healthcare specialist [MHRA, 2016], and expert opinion in a review article on insulin delivery [Frid, 2016] and in the British National Formulary (BNF) [BNF, 2025].

• The recommendation not to change insulin delivery device before the person discusses with their diabetes specialist is based on the MHRA device safety information, which notes that this is important to avoid the risk of hyperglycaemia, hypoglycaemia, or diabetic ketoacidosis (DKA) [MHRA, 2016].
• The information on sharps disposal is based on consensus opinion in a review article, which notes that safe disposal of used sharps is essential to reduce the risk of sharps-related injuries and blood-borne infections [Frid, 2016].
• The information on insulin passports and safety information is based on the RCN guideline [RCN, 2022] and the British National Formulary [BNF, 2025]. 
• The recommendation on wearing or carrying diabetes identification is based on the ISPAD clinical practice consensus guidelines [Adolfsson, 2022]. It is also pragmatic, based on what CKS considers to be safe clinical practice.

Basis for recommendation

The recommendations on injection site problems are based on the National Institute for Health and Care Excellence (NICE) clinical guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2022b] 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) clinical practice consensus guidelines Insulin treatment in children and adolescents with diabetes [Cengiz, 2022], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update Insulins (all types): risk of cutaneous amyloidosis at injection site [MHRA, 2020], and expert opinion in review articles on diabetic reviews [Milne, 2020] and on insulin delivery [Frid, 2016].

• The recommendation to check injection sites if there are problems with blood glucose control is based on the ISPAD clinical practice consensus guidelines [Cengiz, 2022].
• The information about lipodystrophies is based on the RCN publication [RCN, 2022] and the MHRA drug safety update [MHRA, 2020]. The recommendation that suspected cutaneous amyloidosis should be referred to a dermatologist is based on consensus opinion in a review article [Frid, 2016].

Basis for recommendation

The recommendations on poor blood glucose control are based on the National Institute for Health and Care Excellence (NICE) clinical guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2022b], Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023], the joint American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus report Management of hyperglycemia in type 2 diabetes, [Davies, 2022], the International Society for Pediatric and Adolescent Diabetes (ISPAD) clinical practice consensus guidelines Diabetic ketoacidosis and the hyperglycemic hyperosmolar state [Glaser, 2022] and Assessment and management of hypoglycemia in children and adolescents with diabetes [Abraham, 2022], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], and expert opinion in review articles on 'sick-day rules' [Down, 2020] and on hyperglycaemic emergencies [French, 2019].

• The ISPAD clinical practice consensus guidelines note that accidental or deliberate insulin omission is the cause of most cases of recurrent diabetic ketoacidosis (DKA), and underlying psychosocial issues may contribute [Glaser, 2022]. Expert opinion in a review article notes that insulin omission is more often seen in people with eating disorders, people with psychological distress, and fear of hypoglycaemia or weight gain on insulin [French, 2019].
• The joint ADA/EASD consensus report notes the need for frequent blood glucose monitoring and dose titration for optimal efficacy of insulin therapy, and the fact that adverse effects and the need for frequent injections can be barriers to insulin use [Davies, 2022].
• The recommendations on blood glucose monitoring and insulin use during periods of intercurrent illness are based on the RCN guideline [RCN, 2022] and expert opinion in a review article [Down, 2020]. Expert opinion in an additional review article stresses the importance of patient education in managing episodes of intercurrent illness, so that inappropriate reductions or omissions of insulin doses are avoided, which increases the risk of hyperglycaemic emergencies such as DKA or hyperglycaemic hyperosmolar state (HHS) [French, 2019].
• The information on lifestyle issues that can affect blood glucose control is based on the RCN guideline, which notes regular portions of long-acting carbohydrates can help stabilize blood glucose levels, and alcohol can increase the risk of delayed hypoglycaemia [RCN, 2022].
• The information on other medical conditions that can affect blood glucose control and potentially increase the risk of hypoglycaemia is based on the ISPAD clinical practice consensus guidelines [Abraham, 2022].

Advice on insulin storage

Advise the person to check the manufacturer's patient information leaflet for insulin storage information.

• 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.
• Once in use, insulin can generally be stored at room temperature for 28 days (some insulins may be stable for shorter or longer timescales).
  • 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).

Advice on the administration and absorption of insulin

Advise the person and family/carers that:

• Insulin preparations are usually given by subcutaneous injection, as insulin is destroyed by gastric acid and is not absorbed across the gut mucosa.
• 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 1 day to the next in any person. This is due 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:
    • Fat mass — absorption is slower if there is a large amount of subcutaneous fat. 
    • Age — absorption is faster in young children due to less subcutaneous fat.
    • Ambient and body temperature — higher temperatures lead to faster absorption.
    • Injection site — the rate of insulin absorption varies depending on which part of the body is used. This may affect blood glucose control. 
    • Exercise — this causes increased blood flow at the injection site, resulting in faster absorption (for example, thighs of runners). 
    • Inadvertent intramuscular injection — due to factors such as poor injection technique or the use of an inappropriate needle length; absorption is faster compared with subcutaneous injection.
    • Larger dose — absorption is slower if a large insulin dose is injected.

Advice on injection technique

• Advise the person 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.
    • Cold insulin (straight from the fridge) can make the injection painful, and the insulin may take longer to absorb.
  • Check the expiry date before injecting.
    • Any expired insulin should be discarded (it can be returned to the pharmacy for disposal).
  • Inspect the insulin product before injecting.
    • Soluble insulins and long-acting insulin analogues should be clear and colourless and must not be used if they appear cloudy or discoloured.
  • Use the specific product according to the manufacturer's patient information, including:
    • How to prepare the insulin before use — insulin suspension products should be inverted or rotated (not shaken) at least 20 times to mix the insulin. However, soluble insulins and long-acting insulin analogues do not need to be mixed.
    • How to prime the pen — an air shot (sometimes referred to as 'priming the pen') should be done before each injection. This ensures that the plunger is connecting and that any air is expelled from the pen.
    • Never withdrawing insulin from insulin pen devices or pen refills and then administer it using a syringe and needle.
  • Use a new needle for each injection.
    • This reduces the risk of blood-borne infection. In addition, reused needles are less sharp and may cause more painful injections.
  • Choose an appropriate injection site, ensuring that the site and hands are clean. 
    • Advise not to use alcohol wipes unless there are concerns about skin hygiene, as their use can make the injection more painful and harden the skin. Infection at injection sites is rare.
    • A 'two-finger pinch technique' to lift a skinfold to ensure subcutaneous (rather than intramuscular) injection may be used, particularly in young children and thin adults.
    • Do not inject through clothing, as this will prevent skin inspection of the injection site beforehand and make lifting a skinfold and checking for bleeding afterwards difficult.
    • For people injecting more than 50 units (0.5 mL of U100 insulin), many experts recommend splitting the injection into separate areas to facilitate absorption.
  • Inject insulin with the needle at a 90° angle to the skin. The needle should be inserted quickly and all the way in, to ensure injection at a consistent depth.
    • People using long needles (longer than 8 mm) might have to inject at an angle less than 90° to avoid intramuscular injection, however pen needles longer than 4 mm and syringe needles longer than 6 mm are not routinely recommended, as inadvertent intramuscular injection may result in variable blood glucose control and increased risk of hypoglycaemia.
    • The needle should be left in the skin for 5–10 seconds (or longer for large doses), to ensure the entire dose is injected and to avoid leakage of the dose.
  • Apply gentle pressure over the injection site for several seconds after withdrawing the needle.
    • The area should not be rubbed as this may increase the rate of insulin absorption.

Advice on injection sites

Advise the person and family/carers:

• 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 — fastest absorption rate compared with other sites; may be less affected by muscle activity or exercise.
  • Anterolateral thigh — absorption rate slower than abdomen, may be preferred site for longer-acting insulins.
  • Lateral upper quadrant of buttocks — absorption rate is slowest compared with the abdomen and thigh. This site may be useful in small children.
  • Upper arm (not usually recommended) — absorption rate medium to fast.
• The skin should be 'pinched up' to avoid intramuscular injection, if needed.
  • This is recommended especially for slim people, for injection sites that have little subcutaneous fat, and when using long needles. 
  • This may not be necessary when using a very short needle (for example, 4 mm length), or if the buttocks are used due to the abundance of subcutaneous fat.
• To check injection sites regularly for injection site problems, and rotate sites to prevent skin problems such as lipohypertrophy.
  • The person should alternate between the left and right sides of the body on a weekly basis, and injection sites should be rotated within the same area. Each injection should be at least one finger's breadth away from the site of the previous injection.
  • Rotation grids (available from manufacturers of insulin syringes and needles) may be helpful for some people who have problems rotating injection sites.
  • The person should never inject into sites of lipodystrophy, inflammation, oedema, ulceration, or infection.

Advice on driving

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.

• Remind drivers 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.
  • Be aware of how to manage an acute episode of hypoglycaemia, including:
    • Stop the car in a safe place, switch off the engine, and move from the driver's seat.
    • Immediately consume a fast-acting carbohydrate and recheck blood glucose levels frequently until symptoms improve or normal blood glucose is restored. See the section on Managing acute hypoglycaemia for more detailed information.
    • 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.
  • Carry diabetes identification in case of injury in a road traffic collision.
  • Take particular care during changes of insulin regimens, changes of lifestyle, exercise, and travel.
• Group 1 entitlement (to drive a car or motorcycle)
  
  • The person must satisfy the following criteria:
    
    • Has adequate awareness of hypoglycaemia, such that they are 'capable of bringing their vehicle to a safe controlled stop'.
    • Has not had more than one episode of severe hypoglycaemia requiring the assistance of another person in the preceding 12 months, and the most recent episode occurred more than 3 months ago.
    • Performs appropriate blood glucose monitoring, defined as no more than 2 hours before the start of the first journey and every 2 hours after driving has started.
    • Is not regarded as a likely risk to the public while driving.
    • Can meet the visual standards for acuity and visual fields.
    • Is under regular review.
  • Note: more frequent blood glucose self-monitoring may be required if there is a greater risk of hypoglycaemia, for example, after physical activity or altered meal routine.
  • If the medical standards are met, a 1, 2, or 3-year licence will be issued.
• Group 2 entitlement (to drive a bus or lorry)
  • The person must satisfy the following criteria:
    • Has full awareness of hypoglycaemia. 
    • Has not had any episode of severe hypoglycaemia requiring the assistance of another person in the preceding 12 months.
    • Performs regular blood glucose monitoring at least twice daily (including on days when not driving), and at times relevant to driving (no more than 2 hours before the start of the first journey and every 2 hours after driving has started). A maximum of 2 hours should pass between the pre-driving blood glucose test and the first blood glucose check performed after driving has started.
    • Uses a blood glucose meter with sufficient memory to store 3 months of blood glucose readings.
    • Can demonstrate an understanding of the risks of hypoglycaemia.
    • Has no disqualifying complications of diabetes that would mean a license was refused or revoked, such as visual field defect.
  • Note: more frequent blood glucose self-monitoring may be required if there is a greater risk of hypoglycaemia, for example, after physical activity or altered meal routine. A diabetes review is needed at least every 3 years by the person's usual doctor who provides diabetes care, including review of the last 3 months of blood glucose readings. In addition, an annual examination is needed by an independent consultant specialist in diabetes, if the examination by their usual doctor is satisfactory.
  • If the medical standards are met, a 1-year licence will be issued.
• The DVLA patient leaflets A guide to insulin treated diabetes and driving and A guide for drivers with insulin treated diabetes who wish to apply for group 2 entitlement (bus and lorry) may be helpful.
• The Diabetes UK patient resource Driving and diabetes may be helpful.

Advice on insurance

• Inform the person using insulin therapy that:
  • For car insurance, they must notify their insurance company (immediately and on renewal) that they are on insulin therapy.
  • For insurance or assurance for loans and life cover, they must declare their diabetes and any treatment they are taking, including insulin. 
    • If they had not been diagnosed with diabetes at the time they took out an insurance policy, they do not need to inform their insurance company. Their premiums will not change, even if they need to start insulin.
  • For travel insurance, they should check that the policy covers type 2 diabetes, as policies may exclude pre-existing medical conditions.
    • If travelling within the European Union (EU), they should also apply for a Global Health Insurance Card (GHIC) to obtain free or reduced-cost healthcare treatment. This is not a replacement for appropriate travel insurance. See the gov.uk information page Apply for a UK Global Health Insurance Card (GHIC) for more information.
• The Diabetes UK patient resource Insurance and diabetes may be helpful.

Advice on fasting, including Ramadan

Advise people with type 2 diabetes that generally fasting is not recommended, especially if the person has a history of poor blood glucose control, comorbidities, and/or diabetic complications. Fasting for prolonged periods (such as Ramadan) can lead to episodes of hyperglycaemia, ketoacidosis, hypoglycaemia, and dehydration. If a person is planning a period of fasting:

• Advise on the need for pre-fasting education before the start of the fast, including the need to:
  • Optimize blood glucose control, blood pressure, and lipids. See the CKS topic on Diabetes - type 2 for more information.
  • Make adjustments to the type, dose, or timing of the insulin regimen during the fasting period. Seek specialist advice or arrange a referral to the specialist diabetes team if there is any uncertainty about how to adjust insulin therapy.
  • Monitor blood glucose levels frequently during fasting, and how to interpret and act on results. This includes awareness of 'sick-day rules', and recognition and acute treatment of hypoglycaemia. See the CKS topic on Diabetes - type 2 for more information on 'sick-day rules'.
    • Advise the person to break the fast immediately if there is symptomatic hypoglycaemia and/or the blood glucose level is lower than 3.5 mmol/L.
    • Advise the person to avoid fasting if they are unwell.
    • Advise the person to avoid strenuous exercise or activity, particularly during the hours before the sunset meal, as this can increase the risk of hypoglycaemia. Encourage the person to maintain their usual physical activity (especially during non-fasting periods).
• Advise the person on dietary and nutritional adjustments needed during the fasting period:
  • To break the fast, a snack of short-acting carbohydrates such as milk, dates, or juice may be taken.
  • Encourage longer-acting carbohydrates and fruits, vegetables, lean protein, lentils, and yoghurt in the pre-dawn and sunset meals. Limit intake of saturated fats, sweets, and fried foods, and avoid sweetened drinks.
  • Eat the pre-dawn meal as late as possible before the start of the daily fast.
  • Drink water and other non-sweetened drinks at regular intervals during non-fasting hours.
• The Diabetes UK patient resources Diabetes and Ramadan and Religious fasting and diabetes may be helpful.

Advice on work

• Advise people on insulin therapy that some jobs involving safety-critical work will need an individual medical assessment by the employer to determine if the person is suitable for the role; however, it is unlawful for an employer to operate a blanket ban on the recruitment of people with diabetes.
  • The Diabetes UK patient resource Work and diabetes may be helpful.
  • Note: the UK Armed Forces are exempt from Equality Act regulations.
• Advise people that jobs involving shift work may result in an increased risk of poor blood glucose control.
  • If a person has to work shifts, ensure that they know how to adjust their insulin treatment. Arrange referral or liaise with the diabetes specialist team if there is any uncertainty on how to do this.
  • The Diabetes UK patient resource Your lifestyle, diabetes and food may be helpful.

Advice on holidays and travel

• Offer general advice on travelling, such as:
  • Carry some form of diabetes identification at all times.
  • Carry some form of fast-acting carbohydrate to treat possible episodes of hypoglycaemia, and pack longer-acting carbohydrates such as snack bars or biscuits in case of delayed meals.
  • Avoid excessive caffeine and alcohol intake, as these can affect blood glucose control, including hypoglycaemia awareness.
  • Obtain appropriate travel insurance.
  • Take necessary precautions if driving.
  • The Diabetes UK patient resource Travel and diabetes may be helpful.
• Offer advice on insulin management, such as:
  • Carry appropriate quantities of insulin and accessories in their hand luggage (and a spare set on the person, in case their luggage is lost or stolen).
  • Carry supporting documentation from a qualified medical professional explaining the person's need to carry syringes, injection devices, insulin, blood glucose testing equipment, and sharps disposal equipment in their hand luggage, for customs and security measures at airports.
  • Manage their insulin regimen, including adapting the regimen if the time zone change is more than 4 hours.
    • If the person is taking a long-haul flight or will cross different time zones, seek specialist advice or arrange referral to the local diabetes team.

Basis for recommendation

The recommendations on additional information are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Type 2 diabetes in adults: management [NICE, 2022a], the International Society for Pediatric and Adolescent Diabetes (ISPAD) clinical practice consensus guidelines Assessment and management of hypoglycemia in children and adults with diabetes [Abraham, 2022], Exercise in children and adolescents with diabetes [Adolfsson, 2022], Insulin treatment in children and adolescents with diabetes [Cengiz, 2022], and Ramadan and other religious fasting by young people with diabetes [Deeb, 2022]; the Driver and Vehicle Licensing Agency (DVLA) publication Assessing fitness to drive - a guide for medical professionals [DVLA, 2024], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], the NHS Improvement patient safety alert Risk of severe harm and death due to withdrawing insulin from pen devices [NHS Improvement, 2016], and expert opinion in review articles on diabetic reviews [Milne, 2020], on insulin delivery [Frid, 2016], on the management of diabetes during Ramadan [Karamat, 2010; Ibrahim, 2020], and on the management of diabetes during shift work [Young, 2013].

Advice on injection technique

• These recommendations are largely based on the NICE clinical guideline on adults [NICE, 2022a], the ISPAD clinical practice consensus guidelines [Cengiz, 2022], the RCN guidelines [RCN, 2022], an NHS Improvement patient safety alert [NHS Improvement, 2016], and expert opinion in review articles [Frid, 2016; Milne, 2020].
  • The recommendation to never withdraw insulin from pen devices or pen refills is based on an NHS Improvement patient safety alert, which warns this practice may not take account of differing dose strengths in pen devices and may lead to insulin overdose and potentially life-threatening hypoglycaemia if an incorrect volume is extracted inadvertently.
  • The ISPAD clinical practice consensus guidelines note that incorrect angle, length of needle, or depth of injection may cause intramuscular and painful injections.
  • The information that pen needles longer than 4 mm and syringe needles longer than 6 mm are not generally recommended is based on consensus opinion in a review article, which notes that these needle lengths should be used first line as they are safe, effective, and less painful than longer lengths. In addition, it notes the risks of inadvertent intramuscular injection with longer needle lengths [Frid, 2016].

Advice on injection sites

• The information on the absorption characteristics of different body sites is based on the ISPAD clinical practice consensus guidelines, which notes that injection into the arm may be difficult if there is little subcutaneous fat, with an increased risk of intramuscular injection and unsightly bruising [Cengiz, 2022]. The RCN guideline also provides comprehensive information on the different injection sites [RCN, 2022].
• The recommendation to rotate injection sites regularly is based on the NICE clinical guideline on adults [NICE, 2022a], the ISPAD clinical practice consensus guidelines [Cengiz, 2022], and the RCN guideline [RCN, 2022] and is supported by a review article [Frid, 2016].

Advice on driving

• The information on measures to take to avoid and manage an acute episode of hypoglycaemia is based on the ISPAD clinical practice consensus guidelines on hypoglycaemia [Abraham, 2022] and on exercise [Adolfsson, 2022], the RCN guidelines [RCN, 2022], and patient information from Diabetes UK.
• The information on the medical standards for group 1 and group 2 entitlement is based on the DVLA publication [DVLA, 2024]. The RCN guideline highlights the importance of communicating the DVLA driving regulations to people using insulin therapy [RCN, 2022].

Advice on fasting, including Ramadan

• These recommendations are largely based on the ISPAD clinical practice consensus guidelines, which have been extrapolated from recommendations for children and young people with type 1 diabetes on insulin therapy [Deeb, 2022].
  • Optimizing blood glucose control before fasting can help to ensure safe fasting. Hypoglycaemia unawareness needs to be excluded pre-fasting and monitored for during fasting.
  • Adjustments in the insulin regimen, such as reduction of the total daily dose of insulin, may be needed following specialist advice.
  • There is a need to monitor blood glucose levels frequently during fasting periods to minimize the risk of hypoglycaemia and detect periods of hyperglycaemia.
  • Dietary changes are needed to reduce the risk of acute complications of fasting, excessive weight gain, and adverse changes in lipid profile. Low-glycaemic index carbohydrates and lean protein at the pre-dawn meal can enhance satiety during the day.
• These recommendations are supported by the RCN guideline [RCN, 2022] and expert opinion in review articles, which highlight the risks of fasting, and which note the importance of structured education and pre-Ramadan counselling [Karamat, 2010; Ibrahim, 2020].

Advice on work

• The information on medical suitability for employment is based on the RCN guideline [RCN, 2022].
• The information on shift work is extrapolated from expert opinion in a review article on management of type 1 diabetes and shift work, which notes that shift work may lead to differing activity levels, changes to meal times and sleep patterns, and snacking on high-fat foods outside normal working hours [Young, 2013].

Advice on holidays and travel

• The recommendations on travel are largely based on the RCN guideline, which notes that insulin stored in hold baggage will be exposed to very low temperatures which will degrade insulin, and there is a possibility that luggage will be lost en-route [RCN, 2022]. In addition, they are pragmatic, based on what CKS considers to be good clinical practice.

Recognizing hypoglycaemia

Hypoglycaemia (a blood glucose level lower than 3.5 mmol/L) is an inevitable adverse effect of insulin therapy. Advise that the absolute blood glucose level at which signs and symptoms begin to occur can vary between people.

• Ensure that the person and family/carers are aware of the early warning signs of hypoglycaemia, the importance of immediate blood glucose measurement if suspected, and emergency treatment of an acute episode. Hypoglycaemia may present as:
  • Mild — hunger, anxiety or irritability, palpitations, tremor, sweating, or tingling lips.
  • Moderate — headache, drowsiness, difficulty concentrating, impaired vision, confusion, irritability, agitation, and behavioural changes (particularly in children). Impaired cognitive function occurs when blood glucose levels fall below 3.0 mmol/L.
  • Severe — involves severe cognitive impairment such as convulsions, loss of consciousness, and coma. The person is unable to self-manage the hypoglycaemic episode and requires help from another person to achieve normal blood glucose levels.
• The Diabetes UK patient resource What is a hypo? may be useful.
   

Managing a person with impaired awareness of hypoglycaemia

Impaired awareness of hypoglycaemia describes the loss of ability to recognise the usual symptoms of hypoglycaemia, or the absence or blunting of symptoms. Obtain a collateral history from family/carers about the person's awareness of hypoglycaemia, where possible.

• At annual review:
  • Explain that impaired awareness of the symptoms of hypoglycaemia is associated with a significantly increased risk of severe hypoglycaemia, which can be life-threatening.
    • The Driver and Vehicle Licensing Agency (DVLA) defines impaired awareness of hypoglycaemia for group 1 drivers as 'an inability to detect the onset of hypoglycaemia because of total absence of warning symptoms'.
  • Ensure the person and family/carers have appropriate skills and knowledge to use insulin therapy correctly. Offer additional education focusing on avoiding and treating hypoglycaemia if the person continues to have impaired awareness of hypoglycaemia.
  • If the person's target blood glucose levels are lower than recommended, reinforce the recommended treatment targets. 
    • Avoid relaxing individualized blood glucose targets as a treatment for impaired awareness of hypoglycaemia. See the CKS topic on Diabetes - type 2 for more information on recommended treatment targets.
  • Review insulin regimens and doses and prioritize strategies to avoid hypoglycaemia.
    • If the person continues to have impaired awareness of hypoglycaemia and/or recurrent severe hypoglycaemia, liaise with or arrange referral to the diabetes specialist team, the urgency depending on clinical judgement.
  • The Diabetes UK patient resource Hypo unawareness may be useful.

Managing an acute episode of hypoglycaemia

Advise on the acute management of hypoglycaemia:

• If the person is able to swallow: 
  • Children and young people should be given approximately 0.3 g/kg of a fast-acting carbohydrate.
  • Adults should promptly consume 10–20 g of a fast-acting carbohydrate, preferably in liquid form.
  • Examples include:
    • 5 glucose tablets, 6 dextrose tablets, 200 mL (small carton) of fresh fruit juice (not sugar-free or reduced-sugar), 3–4 heaped teaspoonfuls of sugar added to a cup of water, 4 large jelly babies or 7 large jelly beans, or 2 tubes of glucose 40% gel (such as Glucogel^®, Dextrogel^® or Rapilose gel^®).
    • Note: advise to avoid chocolates and biscuits as they have a lower sugar content, and their high fat content may delay stomach emptying.
  • Advise to recheck blood glucose levels after 10–15 minutes. 
    • Hypoglycaemia should be reversed in about 10 minutes.
    • Improvements in clinical signs and symptoms may lag behind improvements in blood glucose level. 
  • If there is no response or an inadequate response, repeat oral intake as above, and re-test blood glucose levels after another 15 minutes.
  • When symptoms improve or normal blood glucose is restored, advise on the need for longer-acting carbohydrate to maintain blood glucose levels and prevent recurrence of hypoglycaemia. 
    • If the next meal is due, it should contain a carbohydrate such as bread, potatoes, or pasta.
    • If the next meal is not due soon, the person should consume a carbohydrate-containing snack such as a sandwich, two plain biscuits, or a banana.
  • The Diabetes UK patient resource  What is a hypo? may be useful.
• If the person is unconscious and unable to swallow (severe hypoglycaemia):
  • Intramuscular (IM) glucagon should be administered immediately. 
    • For children younger than 8 years of age (or body weight less than 25 kg), 500 micrograms of glucagon should be given. 
    • For all other people, 1 mg of glucagon should be given. 
  • Emergency 999 transfer to hospital should be arranged 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, as intravenous (IV) glucose is required. 
  • If the person does not respond to glucagon treatment within 10 minutes, emergency 999 transfer to hospital should be arranged for treatment with IV glucose.
  • If the person responds to glucagon treatment within 10 minutes and is sufficiently alert and able to swallow safely, advise them to eat some oral carbohydrate (to replace the body's supply and to prevent relapse of hypoglycaemia). 
    • Vomiting is common in the recovery phase, and recurrent hypoglycaemia may recur, therefore the person should be closely monitored with regular blood glucose level checks.
    • If hypoglycaemia recurs, the person may require additional oral carbohydrate or emergency 999 hospital admission for treatment with IV glucose if symptoms are severe.

Managing nocturnal hypoglycaemia

• If the person is experiencing symptoms of nocturnal hypoglycaemia (fatigue, headache, or a hangover sensation), and/or if this is detected on blood glucose monitoring: 
  • Review the person's/family's knowledge of blood glucose monitoring and diabetes self-management skills.
  • Review the person's current insulin regimen, evening eating habits, and recent/changes in exercise or physical activity.
  • Advise the person to:
    • Monitor blood glucose levels overnight, including between 2–3 am, when hypoglycaemia is most likely to happen. 
    • Eat a snack before bedtime and keep a source of fast-acting carbohydrate next to the bed.
  • Consider referring the person to the diabetes specialist team for a review of the current insulin regimen.

Preventing hypoglycaemic episodes

• Ensure the person and family/carers have been given information on:
  • How to recognize symptoms of hypoglycaemia, and emergency treatment of episodes of hypoglycaemia.
  • The importance of regular self-monitoring of blood glucose levels.
  • Keeping safe when driving, reducing the risk of hypoglycaemia, self-monitoring of blood glucose levels, and the medical standards that need to be met to be issued a driving licence by the Driver and Vehicle Licensing Agency (DVLA). See the section on Driving for more information.
• If hypoglycaemia becomes troublesome or frequent, assess for contributory factors, such as:
  • Inappropriate insulin regimen, including incorrect dose distributions and insulin types — consider referring the person to the diabetes specialist team for a review of their current insulin regimen.
  • Meal patterns (such as reduced or missed meals), alcohol intake.
  • Exercise/physical activity levels and any recent changes in duration and intensity — hypoglycaemia with exercise may occur at the time of exercise or may be delayed by 7–11 hours.
  • Injection technique and skills.
  • Injection site problems.
  • Impaired awareness of hypoglycaemia; young age or learning disability (may be reduced ability to communicate symptoms).
  • Other medical conditions, such as diabetic gastroparesis, coeliac disease, or Addison's disease. See the CKS topics on Diabetes - type 2, Coeliac disease, and Addison's disease for more information.
  • Changes in insulin sensitivity — an insulin-sensitive person will require smaller amounts of insulin to lower blood glucose levels compared with a person who has low sensitivity.
  • Concomitant drugs that may enhance the blood-glucose-lowering effects of insulin.
  • Lack of appropriate knowledge and skills for self-management of diabetes, or anxiety about hypoglycaemia. The Diabetes UK patient resource What is hypo anxiety? may be helpful.
• If there is recurrent severe hypoglycaemia that has not responded to other treatments, arrange referral or liaise with the specialist diabetes team.

Basis for recommendation

The recommendations on hypoglycaemia are largely based on the National Institute for Health and Care Excellence (NICE) clinical guidelines Type 2 diabetes in adults: management [NICE, 2022a], 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) clinical practice consensus guidelines Assessment and management of hypoglycemia in children and adults with diabetes [Abraham, 2022], Exercise in children and adolescents with diabetes [Adolfsson, 2022], Glycemic control targets and glucose monitoring for children, adolescents, and young adults with diabetes [de Bock, 2022], and Nutritional management in children and adolescents with diabetes [Annan, 2022], the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], the Driver and Vehicle Licensing Agency (DVLA) publication Assessing fitness to drive - a guide for medical professionals [DVLA, 2024], and expert opinion in a review article on diabetes reviews [Milne, 2020] and in the British National Formulary (BNF) [BNF, 2025].

Managing acute hypoglycaemia

• The recommendations on emergency management of acute hypoglycaemia are based on the RCN guideline [RCN, 2022], the ISPAD clinical practice consensus guidelines on hypoglycaemia [Abraham, 2022], and expert opinion in the British National Formulary (BNF) [BNF, 2025].
  • The examples of fast-acting carbohydrates are based on the RCN guideline and the BNF.
  • The examples of longer-acting carbohydrates are based on the RCN guideline.
  • The information on the indications for intramuscular (IM) glucagon and intravenous (IV) glucose is based on the ISPAD guidelines on hypoglycaemia, and expert opinion in the BNF.

Managing nocturnal hypoglycaemia

• The recommendations on nocturnal hypoglycaemia are based on the ISPAD clinical practice consensus guidelines on hypoglycaemia [Abraham, 2022], on exercise [Adolfsson, 2022], and on nutrition [Annan, 2022].
  • The ISPAD guidelines on exercise note that hypoglycaemia may be anticipated during or shortly after exercise and can also occur 7 to 11 hours after exercising for 45 minutes. This means that exercise after 4pm poses a risk of overnight hypoglycaemia.
  • The ISPAD guidelines on hypoglycaemia note that sleep is a risk time for severe hypoglycaemia and asymptomatic hypoglycaemia, and overnight blood glucose monitoring may be needed.
  • The ISPAD guidelines on hypoglycaemia and nutrition note that a carbohydrate snack before bed may be needed for people on some types of insulin therapy to prevent nocturnal hypoglycaemia, but are less likely to be neccessary for users of long-acting insulin analogues such as glargine and detemir. It is advised that the need for pre-bed snacks should be individually tailored.

Preventing hypoglycaemic episodes

• The recommendation on education about hypoglycaemic episodes is based on the ISPAD guidelines on hypoglycaemia [Abraham, 2022]. In addition, expert opinion in a review article states the importance of covering the prevention, signs, symptoms, and management of hypoglycaemia at diabetic reviews; self-monitoring of blood glucose including technique, timing, interpretation and acting on results; as well as the DVLA regulations on driving and hypoglycaemia [Milne, 2020].
• The recommendation that recurrent problematic hypoglycaemia may need a review of insulin regimen is based on expert opinion in a review article, which notes that people with a low HbA1c level and/or recurrent hypoglycaemia may need a dose reduction of insulin. People who are older, frail, with significant weight loss, or receiving palliative care are at risk of overtreatment of hyperglycaemia, which may contribute to episodes of hypoglycaemia [Milne, 2020].
• The information on other contributory factors for recurrent episodes of hypoglycaemia is based on the ISPAD clinical practice consensus guidelines [Abraham, 2022].

Basis for recommendation

The information on possible adverse effects of insulin therapy is based on the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022] and expert opinion in the British National Formulary (BNF) [BNF, 2025].

Basis for recommendation

The information on drug interactions is based on the Royal College of Nursing (RCN) guideline Starting injectable treatment in adults with type 2 diabetes [RCN, 2022], expert opinion in the British National Formulary (BNF) [BNF, 2025], and a pharmaceutical reference book [Preston, 2025].