Type 2 diabetes is a progressive disease characterised by insulin resistance and a decreasing ability of pancreatic β-cells
to produce insulin. Both of these factors contribute to hyperglycaemia. Alongside lifestyle modifications, most patients
with diabetes begin treatment with metformin (with or without other glucose-lowering medicines). However, due to the progressive
nature of type 2 diabetes, treatment with insulin is eventually required in some patients.
Making the decision to initiate insulin
New Zealand guidelines recommend that insulin treatment be considered for any person with type 2 diabetes who has not
met their HbA1c target despite optimal lifestyle modification and pharmacological management with non-insulin
glucose-lowering medicines.1 Insulin initiation is recommended for all patients with significant hyperglycaemia
(e.g. HbA1c > 80 – 90 mmol/mol)* at any stage, including diagnosis.1
* This is higher than previously recommended (75 mmol/mol) due to the availability of more options
to manage hyperglycaemia2
Reinforce the importance of lifestyle interventions
Emphasise to all patients initiating insulin that this is not a substitute for a healthy lifestyle and that behavioural
strategies such as exercise, healthy eating and smoking cessation should still continue. Alcohol consumption should be limited
as this increases the risk of hypoglycaemia in patients taking insulin.
It may be possible for some people with type 2 diabetes, following significant weight loss, to stop taking insulin, especially
if they have had diabetes for a short period, now have a body mass index (BMI) < 30 kg/m2 and are close to
or at their HbA1c target.
For further information on weight management, see:
Weight loss: the options and the evidence
When to seek further advice
Advice about an insulin regimen should be sought from a diabetes clinic in cases where:3
- The patient is a child or adolescent
- The patient is very lean or has lost weight rapidly – testing for glutamic acid decarboxylase (GAD) autoantibodies indicating type 1 diabetes may be appropriate
- There is repeated hypoglycaemia
- The patient is a vocational driver
- HbA1c levels remain above target following insulin initiation and titration – the HbA1c target
should ideally be reached within three to six months of treatment initiation and optimisation4
There are three main types of insulin regimens used by people with type 2 diabetes: basal, basal-bolus and biphasic
(see: Funded insulins available in New Zealand). Selection
of a regimen should be guided by the pattern of blood glucose results and individual patient factors (also see: “Treatment
intensification: basal-bolus or biphasic?”). Typically, people with type 2 diabetes are initiated on basal insulin.
For a schematic representation comparing the duration of different insulins, see:
www.nzf.org.nz/nzf_3629
Basal regimens use an intermediate/long-acting insulin (basal insulin) injected once or twice daily.
Basal insulin reduces HbA1c by controlling hepatic glucose production. There are two types of basal insulin available
fully funded in New Zealand (see: “Funded insulins available in New Zealand” for brand names and product
variations):
- Isophane insulin (e.g. Humulin NPH or Protaphane), also known as NPH* insulin, is an intermediate-acting insulin – suitable
for most patients
- Insulin glargine (e.g. Lantus), an insulin analogue, is a long-acting insulin – consider switching to this insulin if
patients have significant hypoglycaemia with isophane insulin5
*Neutral Protamine Hagedorn (NPH)
Basal-bolus regimens use a rapid/short-acting (bolus) insulin injected before or with meals and snacks
and an intermediate/long-acting (basal) insulin injected once or twice daily. Rapid/short-acting formulations reduce HbA1c by
decreasing post-prandial glucose levels. Basal-bolus insulin regimens are usually administered as a flexible dose (i.e.
carbohydrate counting to match insulin requirements to the carbohydrate content of the upcoming meal) but some patients
may use a fixed dose, depending on their circumstances, e.g. if they are unable to count carbohydrates.
For information on carbohydrate counting, see:
bpac.org.nz/2019/diabetes-insulin.aspx
Biphasic regimens use an intermediate-acting insulin mixed with a short-acting insulin, injected twice
daily, i.e. before breakfast and dinner. Biphasic regimens are an alternative to basal-bolus regimens for patients who are
taking basal insulin and require treatment intensification. A variety of pre-mixed biphasic insulins with differing proportions
of intermediate-acting and short-acting insulin are funded (See Table 2 in Funded insulins available in New Zealand).
A reasonable initial choice is
a biphasic insulin containing a rapid-acting insulin analogue, e.g. Humalog Mix25 (biphasic insulin lispro) or Novomix30
(insulin aspart), because of the faster onset of action than those containing human neutral insulin, allowing patients to
“inject and eat”. Humalog Mix50 may be helpful if the premixed insulin is administered with a large carbohydrate-based meal,
particularly if the patient has postprandial hyperglycaemia with mixes containing 25% or 30% rapid/short-acting insulin.1
Funded insulins available in New Zealand
Tables 1 and 2 show the funded insulin brand names and product variations available in New Zealand. The delivery device
depends on the type of insulin used. There is some variability in the pens provided by different manufacturers which may
make one preferable to another, e.g. maximum number of doses, whether they deliver insulin in half-unit increments, size
of the dial, pressure needed on the injection button to deliver the dose.11 “Memory pens” that remember
the time and size of the last dose are also available.
In order to reduce the risk of prescription errors with insulin ensure:
- To use the full brand name
of the insulin when prescribing – take care with products that have similar names, e.g. Humalog, Humalog Mix and Humulin;
Novomix and Novorapid
- The patient understands
their regimen, i.e. the type(s) of insulin and when to use, and knows to discuss with the prescriber if their prescription
is different from usual
- The patient knows to discuss
with the pharmacist if the product or packaging looks different from what they usually receive
- Ensure that any changes
in insulin regimen are explained to the patient and clearly understood
Table 1: Funded short, intermediate and long-acting insulins as of June, 2022.12
Insulin |
Manufacturer |
Brand |
Formulation* |
Injection device** |
Time course (subcutaneous injection) |
Rapid/short-acting insulin |
Insulin aspart |
Novo Nordisk |
Novorapid |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Onset: 10 – 20 minutes
Peak: 1 hour
Duration: 2 – 5 hours
|
Novorapid Penfill |
3 mL cartridge × 5 |
Use with Novo Nordisk insulin delivery systems |
Novorapid FlexPen |
3 mL prefilled disposable device × 5 |
Insulin glulisine |
Sanofi-Aventis |
Apidra |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
3 mL cartridge × 5 |
Use with the following reusable injection pens:
- AllStar
- AllStar Pro
- JuniorStar
- ClikStar
|
Apidra Solostar |
3 mL disposable device × 5 |
Insulin lispro |
Eli Lilly |
Humalog |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
3 mL cartridge × 5 |
Use with HumaPen injection device |
Short-acting insulin |
Human neutral insulin |
Novo Nordisk |
Actrapid |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Onset: 30 – 60 minutes
Peak: 2 – 4 hours
Duration: up to 8 hours
|
3 mL cartridge × 5 |
Use with Novo Nordisk insulin delivery systems |
Eli Lilly |
Humulin |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Humulin R |
3 mL cartridge × 5 |
Use with HumaPen injection device |
Intermediate-acting insulin |
Isophane insulin |
Eli Lilly |
Humulin NPH |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Onset: 1 – 2 hours
Peak: 4 – 12 hours
Duration: 8 – 24 hours
|
3 mL cartridge × 5 |
Use with HumaPen injection device |
Novo Nordisk |
Protaphane |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Protaphane Penfill |
3 mL cartridge × 5 |
Use with Novo Nordisk insulin delivery systems |
Long-acting insulin |
Insulin glargine |
Sanofi-Aventis |
Lantus |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Onset: 1 – 2 hours
No pronounced peak
Duration: 24 hours
|
3 mL cartridge × 5 |
Use with the following reusable injection pens:
- AllStar
- AllStar Pro
- JuniorStar
- ClikStar
|
Lantus SoloStar |
3 mL disposable device × 5 |
* All funded insulin formulations are at a concentration of 100 units/mL. Three months’ supply may be dispensed at one time
if endorsed “certified exemption” by the prescriber or pharmacist.
** Injection syringes and pen needles may be prescribed with subsidy if prescribed on the same form as insulin or if the patient has
previously had a prescription of insulin and the prescription is endorsed; pharmacists may endorse the prescription if there
is a prior record of insulin dispensing13
Table 2: Funded biphasic insulins as of June, 2022.12
Insulin |
Manufacturer |
Brand |
Mix |
Rapid/short-acting insulin component |
Intermediate-acting insulin component |
Formulation* |
Injection devices** |
Biphasic insulin lispro |
Eli Lilly |
Humalog Mix25 |
25/75 |
Insulin lispro 25 units/mL |
Insulin lispro protamine‡ 75 units/mL |
3 mL cartridges × 5 |
For use with HumaPen injection device |
Humalog Mix50 |
50/50 |
Insulin lispro 50 units/mL |
Insulin lispro protamine‡ 50 units/mL |
3 mL cartridges × 5 |
Biphasic isophane insulin |
Eli Lilly |
Humulin 30/70 |
30/70 |
Neutral human insulin 30 units/mL |
Isophane insulin 70 units/mL |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
|
|
|
|
3 mL cartridge × 5 |
For use with HumaPen injection device |
Novo Nordisk† |
Mixtard 30 |
30/70 |
Neutral human insulin 30 units/mL |
Isophane insulin 70 units/mL |
10 mL vial × 1 |
Prescribe injection syringes with attached needle |
Penmix 30 |
30/70 |
Neutral human insulin 30 units/mL |
Isophane insulin 70 units/mL |
3 mL cartridge × 5 |
For use with Novo Nordisk insulin delivery systems |
Penmix 50 |
50/50 |
Neutral human insulin 50 units/mL |
Isophane insulin 50 units/mL |
3 mL cartridge × 5 |
Biphasic insulin aspart |
Novo Nordisk |
Novomix 30 |
30/70 |
Insulin aspart 30 units/mL |
Insulin aspart protamine‡ 70 units/mL |
Prefilled disposable devices × 5 (FlexPen) |
* All funded insulin formulations are at a concentration of 100 international units/mL. Three months’ supply may be dispensed at
one time if endorsed “certified exemption” by the prescriber or pharmacist.
†Novo Nordisk brands of biphasic insulin isophane with insulin neutral (Mixtard 30, Penmix 30 and Penmix 50) are being discontinued. Penmix 40 was discontinued in 2022. Mixtard 30, Penmix 30 and Penmix 50 will continue to be listed on the Pharmaceutical Schedule until stock is exhausted (final shipment due by 30th September, 2024).
** Injection syringes, needles and pen needles are subsidised if prescribed on the same form as insulin or if the patient
has previously had a prescription of insulin and the prescription is endorsed; pharmacists may endorse the prescription if there is a prior record
of insulin dispensing13
‡ Insulin lispro protamine and insulin aspart protamine are intermediate-acting insulins that are only
available as part of premixed biphasic preparations in New Zealand
Patients using insulin should begin self-monitoring of blood glucose
Self-monitoring of blood glucose is recommended to help guide insulin dosing and meal planning. For patients
with type 2 diabetes initiating basal insulin, a once daily measurement is usually sufficient, taken either:
- Before breakfast (fasting) if initiating insulin injections in the evening; OR
- Prior to evening dinner if initiating insulin injections in the morning
The aim of treatment is to achieve blood glucose levels between 6 – 8 mmol/L at these times.3
For some patients self-monitoring of blood glucose levels may be useful before initiating insulin to determine their daily
pattern of glycaemia, e.g. before and after main meals for three days prior to initiation.
Various blood glucose meters are available fully funded
There are three blood glucose testing meters currently fully funded* for people with type 2 diabetes who are
taking insulin:6, 7
- CareSens N – big screen and large numbers
- CareSens N Pop – small, slim meter; backlit for testing in low light environments
- CareSens N Premier – big screen and large numbers; bluetooth functionality
These meters all use the CareSens N blood glucose test strips. Patients should be encouraged to keep a record of their
blood glucose measurements, as well as noting any changes to their normal diet, routine or health. Logbooks are available
from diabetes clinics or diabetes medicine manufacturers. All funded blood glucose meters can be read by the SmartLog software
supplied by the manufacturer at no cost to the patient. Patients should bring their meter and logbook to their appointments.
A variety of smartphone apps are also available to record data.
*The CareSens-Dual meter measures blood glucose and blood ketones (using the CareSens PRO and
KetoSens test strips); this meter is not funded for people with type 2 diabetes
N.B. Although mainly used by people with type 1 diabetes, continuous blood glucose monitoring may be useful in some people
with type 2 diabetes taking insulin.8 For further information on continuous blood glucose monitoring, see: bpac.org.nz/2019/diabetes-insulin.aspx
Patient information on diabetes smartphone apps is available from: www.healthnavigator.org.nz/apps/d/diabetes-apps/
Recommended initial isophane treatment regimen
New Zealand guidelines recommend starting with once daily basal insulin, administered in the evening to help reduce high
blood glucose levels in the morning.1 However, administering the injection in the morning may be appropriate
for some patients who have increases in blood glucose levels throughout the day (Table 3).
Table 3. Patient characteristics to guide once daily dosing of basal insulin9
Once daily injections at night are suitable for patients: |
Once daily injections in the morning are suitable for patients with: |
- With high blood glucose levels in the morning
- At lower risk of nocturnal hypoglycaemia
- Who can respond to a nocturnal hypoglycaemic event, e.g. have no mobility issues or can rely on assistance from
others
|
- Blood glucose levels that increase throughout the day
- Increased risk of nocturnal hypoglycaemia
- Increased risk of consequences of a nocturnal hypoglycaemia event, e.g. living alone, frailty, risk of falls
|
A weight-based approach is recommended to determine the initial basal insulin dose:1
- 0.1 units/kg daily if any of:
- HbA1c < 64 mmol/mol
- BMI < 18 kg/m2 (less likely to have type 2 diabetes)
- Older (e.g. aged > 65 years) or frailty
- Renal or liver failure
- 0.2 units/kg daily if HbA1c > 64 mmol/mol and BMI > 18 kg/m2
Patients will need to titrate the insulin dose upwards from this starting point based on their fasting blood glucose levels.
Having patients adjust their own doses, rather than waiting for instructions from a clinician, is usually a more successful
approach for achieving HbA1c targets.10
There are different methods for titration; New Zealand guidelines recommend increasing the dose by 10% or 2 units if patients
have three consecutive days of fasting blood glucose levels > 7 mmol/L (i.e. the dose can be increased every three days).1
The upwards titration of basal insulin should be stopped if:1
- Hypoglycaemia occurs (blood glucose levels < 4 mmol/L); OR
- Fasting blood glucose levels are < 7 mmol/L; OR
- Dose > 0.5 units/kg/day – consider adding a rapid/short-acting insulin (usually one dose with the largest meal)
If fasting blood glucose levels < 6 mmol/L are recorded, insulin doses should be reduced:3
- Between 4 – 6 mmol/L: decrease insulin dose by 2 units
- < 4 mmol/L: decrease insulin dose by 4 units
Treatment intensification: basal-bolus or biphasic?
Treatment intensification should be considered for patients who have not reached their HbA1c target after three
months’ treatment with basal insulin, despite achieving fasting blood glucose levels < 7 mmol/L and/or taking a dose
of 0.5 units/kg/day.1 The choice of intensification to a basal-bolus or biphasic regimen should be based on patient
characteristics and preference (Table 4).
Table 4. Factors influencing the choice between a basal-bolus and biphasic regimen1
Factor/characteristic |
Basal-bolus |
Biphasic (i.e. premixed) |
Allows flexibility, e.g. for work patterns, exercise |
Yes |
No |
Allows for varied diet and meal times |
Yes |
No |
Likely requires rapid treatment intensification |
Yes |
No |
Level of ability required to manage injections, e.g. cognitive, dexterity |
Higher |
Lower |
Frequency of blood glucose monitoring |
More frequent |
Less frequent |
Frequency of injections |
More frequent |
Less frequent |
A treatment algorithm from the NZSSD type 2 diabetes management guideline (2021) is available
from: t2dm.nzssd.org.nz/Insulin-Algorithm.html
Initiating a basal-bolus regimen
When adding bolus insulin to a basal regimen, start with a rapid-acting insulin immediately before the largest meal (also
known as a “basal plus” regimen):1
- Start with 4 units or 10% of the basal dose (maximum starting dose is 10 units)
- Stop sulfonylurea once established on bolus insulin
- Continue lifestyle management and other glucose-lowering medicines
- Monitor blood glucose levels before and two hours after that meal
- Basal insulin dose may need to be reduced to prevent hypoglycaemia, particularly if HbA1c levels < 64 mmol/mol
Increase the dose of rapid-acting insulin by 2 units if blood glucose level increase with the meal is > 3
mmol/L on three occasions. Adherence and injection technique should be checked before increasing doses.
Add bolus insulin at other meals if HbA1c remains above the target or blood glucose levels
increase by > 3 mmol/L at other meals. N.B. The doses of bolus insulin are likely to be different at different meals.
Add correction doses of rapid-acting insulin to treat pre-meal hyperglycaemia. The calculation
is: 1 unit for every x mmol over 8 mmol/L, based on the total daily dose of basal + bolus insulin (see: Table
5 and "Example of how to calculate a correction dose of insulin"). Initially it may be safer to limit the correction dose to a maximum of 6 – 10 units.
Other correction doses may be added, e.g. before bed, but there should be at least three hours before correction doses.1
Table 5. Correction insulin dose calculation based on total daily insulin dose1
Total daily dose of basal + bolus insulin |
Correction dose calculation |
≤ 25 units/day |
1 unit for every 4 mmol > 8 mmol/L |
26 – 40 units/day |
1 unit for every 3 mmol > 8 mmol/L |
41 – 75 units/day |
1 unit for every 2 mmol > 8 mmol/L |
≥ 76 units/day |
1 unit for every 1 mmol > 8 mmol/L |
Example of how to calculate a correction dose of insulin
If a patient is taking 40 units of basal insulin once daily (evening dosing) and 10 units of bolus insulin with meals their total
daily dose is 70 units per day, so their starting correction is 1 unit for every 2 mmol > 8 mmol/L.
Table 6. Example correction insulin dose based on blood glucose levels and total daily dose of 70 units insulin daily1
Blood glucose level (mmol/L) |
Correction dose of insulin (unit) |
Total insulin dose (bolus + correction) with meal (unit) |
< 10 |
0 |
10 |
10 – 11.9 |
1 |
11 |
12 – 13.9 |
2 |
12 |
14 – 15.9 |
3 |
13 |
16 – 17.9 |
4 |
14 |
18 – 19.9 |
5 |
15 |
≥ 20 |
6 |
16 |
Initiating a biphasic regimen
Emphasise to patients the importance of premixing insulin by gently inverting the device before each use
to reduce the risk of hypoglycaemia.
The type of biphasic regimen depends on whether the patient predominantly has one large meal per day or multiple meals
per day (Table 7). Adherence and injection technique should be checked before any dose increases.
If after three months of optimised treatment HbA1c levels remain above the target, consider:1
- Switching one or both injections to Humalog Mix50 if significant hyperglycaemia after meals
- Adding bolus insulin at other meals if blood glucose levels increase > 3 mmol/L at these times (e.g. lunch, large
snacks)
- Switching to a basal-bolus regimen
Table 7. Guide for initiating biphasic insulin in people with type 2 diabetes1
Predominately one large meal per day |
Multiple meals per day |
Start once daily premixed insulin:
- Convert the daily dose of basal insulin to premixed insulin
- Administer before the largest meal
- Monitor blood glucose levels before and two hours after that meal
- Increase dose by 10% if blood glucose level increase with that meal is > 3 mmol/L and fasting blood glucose level
is > 10 mmol/L
|
Start twice daily premixed insulin:
- Convert the daily of dose basal insulin to premixed insulin
- Administer half the dose before breakfast and the other half before dinner; consider a different ratio if there
is a large difference in meal sizes or the patient is older, e.g. 2/3 of the total daily insulin dose before the larger
meal and 1/3 before the smaller meal; older people should have lower evening doses
- Monitor blood glucose levels before and two hours after that meal
- If on three occasions blood glucose levels increase > 3 mmol/L with breakfast and pre-dinner blood glucose levels
are > 10 mmol/L, increase the breakfast dose by 10%
- If on three occasions blood glucose levels increase > 3 mmol/L with dinner and pre-breakfast blood glucose levels
are > 10 mmol/L, increase the dinner dose by 10%
|
Ongoing advice and education are paramount to ensure patients are confident with their prescribed insulin regimen.
An initial session for patients starting insulin should cover:1, 3, 4
- Self-monitoring of blood
glucose levels
- How to use their injection
device, injection technique and rotation of injection sites
- Appropriate storage of
insulin and disposal of injection devices and needles
- How to titrate the insulin
dose based on self-measurement of blood glucose levels
- What to do during disruptions
to their typical daily routine, such as if they are acutely unwell, miss meals or are travelling
- Managing hypoglycaemia
(see: "Managing hypoglycaemia"), including how diet and exercise can affect the risk,
recognising symptoms, testing blood glucose levels during suspected hypoglycaemia and how to respond if levels
are too low
- Driving safely while using
insulin and any impact using insulin may have on their fitness to drive (see:
t2dm.nzssd.org.nz/Section-100-Diabetes-and-driving)
- Use of a Medic Alert bracelet
The initial session will likely require a longer consultation time and/or a team approach with the general practitioner,
nurse practitioner or practice nurse; consider referral to a diabetes nurse specialist or education programme covering the
above points if offered by the local DHB or PHO.
After the initiation of insulin, make regular contact with the patient, e.g. phone calls from the practice nurse with
in-person or virtual consultations, as required, until satisfactory glycaemic control is achieved.
Managing hypoglycaemia
Symptomatic hypoglycaemia can occur when a person’s blood glucose level falls below 4.0 mmol/L.1 People taking
insulin need to be alert for the symptoms of hypoglycaemia and know how to manage the condition. The most common reasons
for hypoglycaemia occurring in a person with type 2 diabetes are a lack of food, an increase in physical activity, administration
of insulin or less commonly, a sulfonylurea, administering insulin into new sites if previous sites had lipohypertrophy,
declining renal function or consumption of alcohol without food.1
Symptoms of hypoglycaemia include:1
- Hunger
- Blurred vision, headache, light-headedness
- Loss of concentration, confusion, irritability, fatigue
- Sweating, tingling around mouth and lips, trembling, weakness and possible loss of consciousness
A person with diabetes who suspects they are hypoglycaemic should stop what they are doing, sit down and check their blood
glucose level. Hypoglycaemia is treated by consuming rapid-acting carbohydrate: 0.3 g/kg of body weight OR 30
g total (see below). N.B. weight-based management of hypoglycaemia is more effective.1
Examples of 30 g* of rapid-acting carbohydrate include:1
- 10 Dextro-Energy or Vita glucose tablets or 6 BD brand glucose tablets
- 30 g of glucose powder
- 6 teaspoons of sugar dissolved in water
- 350 mL of fruit juice or non-diet/zero soft drink
- 18 jellybeans
- 2 tablespoons of honey
- 3 tablespoons of jam
- 2 Hypofit gels
*Previously, a lower dose, e.g. 12 – 15 g was recommended. However, data from a 2018 New Zealand-based
study has shown that 30 g glucose is more effective than the lower doses at resolving hypoglycaemia in people with type
2 diabetes.14
After ten minutes blood glucose levels should be reassessed and more glucose taken if required. This process should continue
until blood glucose levels are above 4.0 mmol/L. A carbohydrate snack such as a slice of toast, two biscuits or crackers
with cheese should then be eaten and blood glucose levels rechecked after 30 minutes.1 Encourage patients to
report any episodes of hypoglycaemia to their general practice as a change in insulin dose may be needed. The use of a MedicAlert
bracelet is also recommended.
Ensure patients and their family/whānau are aware that if they experience a lowered level of consciousness, unusual behaviour
or seizures, immediate medical attention must be sought (i.e. call an ambulance).
Best Practice tip: Patients who believe they may be experiencing nocturnal hypoglycaemia
can confirm this by setting an alarm and performing a blood glucose test during the night (e.g. at 3 am) on several occasions.
Further resources
Diabetes group education classes are offered by local Diabetes Centres. Diabetes New Zealand provides additional information
on subjects such as healthy eating and exercise as well as providing links to support groups and research publications.
Pamphlets for patients can be downloaded or ordered from:
https://www.diabetes.org.nz/pamphlet-ordering
The Diabetes New Zealand “Take Control Toolkit” for patients is available at no cost as a smartphone app:
https://www.diabetes.org.nz/take-control-toolkit-1