open access

Vol 8, No 3 (2019)
REVIEW ARTICLES
Published online: 2019-06-19
Get Citation

Practical guidance on insulin injection practice in diabetes self-management in the Indian setting: an expert consensus statement

Rajeev Chawla, Minakshisundaram Shunmugavelu, Brij Makkar, Manoj Chawla, Abhay Sahoo, Sujoy Majumdar, Sailesh Lodha, Sunil Gupta, Anil Bhansali
DOI: 10.5603/DK.2019.0013
·
Clinical Diabetology 2019;8(3):176-194.

open access

Vol 8, No 3 (2019)
REVIEW ARTICLES
Published online: 2019-06-19

Abstract

This consensus statement aimed to provide a simple and easily implementable practical educational guide- line for healthcare professionals (HCPs) and patients regarding insulin injection practice in diabetes self- management in the Indian setting.

A group of experts analysed published data from guidelines, clinical trials and real world evidence to reach consensus recommendations on optimal insulin injection practices in terms of a) the injection sites (preparation of site of injection, choosing the injec- tion site, site rotation), b) choice of device and storage of insulins, and c) safety precautions, sharp disposal practice and complications.

Findings from Global and Indian arm of 2014-2015 ITQ Study were considered to emphasize a need for improved practice by HCPs covering all the vital topics essential to proper injection habits.

The consensus statement provides a simple and easily implementable practical educational guideline for HCPs and patients to optimize insulin injection practices in accordance with recent advances in device manufac- turing, newer research findings, and updated interna- tional guidelines as well as widespread concerns about neglected safety precautions such as single-patient use of pens and appropriate sharp disposal practices.

Abstract

This consensus statement aimed to provide a simple and easily implementable practical educational guide- line for healthcare professionals (HCPs) and patients regarding insulin injection practice in diabetes self- management in the Indian setting.

A group of experts analysed published data from guidelines, clinical trials and real world evidence to reach consensus recommendations on optimal insulin injection practices in terms of a) the injection sites (preparation of site of injection, choosing the injec- tion site, site rotation), b) choice of device and storage of insulins, and c) safety precautions, sharp disposal practice and complications.

Findings from Global and Indian arm of 2014-2015 ITQ Study were considered to emphasize a need for improved practice by HCPs covering all the vital topics essential to proper injection habits.

The consensus statement provides a simple and easily implementable practical educational guideline for HCPs and patients to optimize insulin injection practices in accordance with recent advances in device manufac- turing, newer research findings, and updated interna- tional guidelines as well as widespread concerns about neglected safety precautions such as single-patient use of pens and appropriate sharp disposal practices.

Get Citation

Keywords

insulin injection practices; guidelines; injection site; site rotation; storage; disposal; safety; complications

About this article
Title

Practical guidance on insulin injection practice in diabetes self-management in the Indian setting: an expert consensus statement

Journal

Clinical Diabetology

Issue

Vol 8, No 3 (2019)

Pages

176-194

Published online

2019-06-19

DOI

10.5603/DK.2019.0013

Bibliographic record

Clinical Diabetology 2019;8(3):176-194.

Keywords

insulin injection practices
guidelines
injection site
site rotation
storage
disposal
safety
complications

Authors

Rajeev Chawla
Minakshisundaram Shunmugavelu
Brij Makkar
Manoj Chawla
Abhay Sahoo
Sujoy Majumdar
Sailesh Lodha
Sunil Gupta
Anil Bhansali

References (69)
  1. International Diabetes Federation. IDF Diabetes Atlas Update 2017. 8th ed. Available from: http://www.diabetesatlas.org.
  2. World Health Organization. Global Report on Diabetes 2016. (NLM Classification: WK 810) 2016. Available from: http://www.apps.who.int/iris/bitstream/10665/204871/1/9789241565257_eng.pdf.
  3. Akhtar S, Dhillon P. Prevalence of diagnosed diabetes and associated risk factors: Evidence from the large-scale surveys in India. J Soc Health Diabetes. 2018; 5(1): 28–36.
  4. Frid A, Hirsch L, Gaspar R, et al. Scientific Advisory Board for the Third Injection Technique Workshop. New injection recommendations for patients with diabetes. Diabetes Metab. 2010; 36 Suppl 2: S3–18.
  5. Tandon N, Kalra S, Balhara YP, et al. Forum for injection technique and therapy expert recommendations, India: the Indian recommendations for best practice in insulin injection technique, 2017. Indian J Endocrinol Metab. 2017; 21(4): 600–617.
  6. Gururaj Setty S, Crasto W, Jarvis J, et al. New insulins and newer insulin regimens: a review of their role in improving glycaemic control in patients with diabetes. Postgrad Med J. 2016; 92(1085): 152–164.
  7. De Coninck C, Frid A, Gaspar R, et al. Results and analysis of the 2008-2009 Insulin Injection Technique Questionnaire survey. J Diabetes. 2010; 2(3): 168–179.
  8. Patil M, Sahoo J, Kamalanathan S, et al. Assessment of insulin injection techniques among diabetes patients in a tertiary care centre. Diabetes Metab Syndr. 2017; 11 Suppl 1: S53–S56.
  9. Kapoor U, Ramasamy G, Selvaraj K, et al. Does one-to-one demonstration with insulin pads by health-care providers improves the insulin administration techniques among diabetic patients of a Tertiary Care Teaching Hospital in South India? Indian J Endocrinol Metab. 2016; 20(6): 767–771.
  10. Frid AH, Hirsch LJ, Menchior AR, et al. Worldwide injection technique questionnaire study: population parameters and injection practices. Mayo Clin Proc. 2016; 91(9): 1212–1223.
  11. Davidson JA. New injection recommendations for patients with diabetes. Diabetes Metab. 2010; 36 Suppl 2: S2.
  12. Siminerio L, Kulkarni K, Meece J, et al. Strategies for insulin injection therapy in diabetes self-management. Diabetes Educ. 2011; 37: 1–10.
  13. Dolinar R. The importance of good insulin injection practices in diabetes management. US Endocrinology. 2009; 5(1): 49–52.
  14. Brod M, Alolga SL, Meneghini L. Barriers to initiating insulin in type 2 diabetes patients: development of a new patient education tool to address myths, misconceptions and clinical realities. Patient. 2014; 7(4): 437–450.
  15. Okazaki K, Goto M, Yamamoto T, et al. Barriers and facilitators in relation to starting insulin therapy in type 2 diabetes. Diabetes. 1999; 48: SA319–SA319.
  16. Jha S, Panda M, Kumar S, et al. Psychological insulin resistance in patients with type 2 diabetes. J Assoc Physicians India. 2015; 63(7): 33–39.
  17. Davel H, Berg GI, Allie R, et al. Injection technique guidelines for diabetes: sharp and to the point. J Endocrinol Metab Diabetes S Afr. 2014; 19(1): 8–13.
  18. Tandon N, Kalra S, Balhara YP, et al. Forum for injection technique (FIT), India: the Indian recommendations 2.0, for best practice in insulin injection technique, 2015. Indian J Endocrinol Metab. 2015; 19(3): 317–331.
  19. Kalra S, Mithal A, Sahay R, et al. Indian injection technique study: population characteristics and injection practices. Diabetes Ther. 2017; 8(3): 637–657.
  20. Poudel RS, Shrestha S, Piryani RM, et al. Assessment of insulin injection practice among diabetes patients in a tertiary healthcare centre in Nepal: a preliminary study. J Diabetes Res. 2017; 2017: 8648316.
  21. Ji J, Lou Q. Insulin pen injection technique survey in patients with type 2 diabetes in mainland China in 2010. Curr Med Res Opin. 2014; 30(6): 1087–1093.
  22. Berard L, Desrochers F, Husband A, MacNeill G, Roscoe R; Canadian Diabetes Association FIT Board. Canadian Forum of Injection techniques (FIT) Recommendations for Best Practice in Injection Technique, 2012 https://www.bd.com/resource.aspx?IDX=25063.
  23. Hicks D, Adams D, Diggle J, Gelder C. FIT Board. UK Forum of Injection techniques (FIT) Recommendations for Best Practice in Injection Technique, 2015 http://www.fit4diabetes.com/files/6714/4293/6325/FIT_Injection_Technique_Recommendations_3rd_Edition_lo_res.pdf.
  24. American Association of Diabetes Educators (AADE) Strategies for Insulin Injection Therapy in Diabetes Self-Management, 2011 https://www.bd.com/resource.aspx?IDX=25123.
  25. American Diabetes Association. Insulin administration. Diabetes Care. 2004; 27(Suppl 1): S106–S109.
  26. Frid AH, Hirsch LJ, Menchior AR, et al. Worldwide injection technique questionnaire study: population parameters and injection practices. Mayo Clin Proc. 2016; 91(9): 1212–1223.
  27. Hildebrandt P, Hildebrandt P. Skinfold thickness, local subcutaneous blood flow and insulin absorption in diabetic patients. Acta Physiol Scand Suppl. 1991; 603(4): 41–45.
  28. Hildebrandt P. Subcutaneous absorption of insulin in insulin-dependent diabetic patients: influence of species, physicochemical properties of insulin and physiological factors. Dan Med Bull. 1991; 38: 337–346.
  29. Gagnon-Auger M, du Souich P, Baillargeon JP, et al. Dose-dependent delay of the hypoglycemic effect of short-acting insulin analogs in obese subjects with type 2 diabetes: a pharmacokinetic and pharmacodynamic study. Diabetes Care. 2010; 33(12): 2502–2507.
  30. Gibney MA, Arce CH, Byron KJ, et al. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendations. Curr Med Res Opin. 2010; 26(6): 1519–1530.
  31. Karges B, Boehm BO, Karges W. Early hypoglycaemia after accidental intramuscular injection of insulin glargine. Diabet Med. 2005; 22(10): 1444–1445.
  32. Hirsch L, Byron K, Gibney M. Intramuscular risk at insulin injection sites--measurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous insulin therapy. Diabetes Technol Ther. 2014; 16(12): 867–873.
  33. Wood L, Wilbourne J, Kyne-Grzebalski D. Administration of insulin by injection. Pract Diabetes Int. 2002; 19(2): S1–S4.
  34. Ahern J, Mazur ML. Mazur ML. Site rotation Diabetes Forecast. 2001; 54: 66–68.
  35. Yadav S, Parakh A. Insulin therapy. Indian Pediatr. 2006; 43(10): 863–872.
  36. Kalra S, Mithal A, Sahay R, et al. Indian injection technique study: injecting complications, education, and the health care professional. Diabetes Ther. 2017; 8(3): 659–672.
  37. Davis ED, Chesnaky P. Site rotation.Taking insulin. Diabetes Forecast. 1992; 45: 54–56.
  38. Frid AH, Hirsch LJ, Menchior AR, et al. Worldwide injection technique questionnaire study: injecting complications and the role of the professional. Mayo Clin Proc. 2016; 91(9): 1224–1230.
  39. Photographs courtesy of Lourdes Saez-de Ibarra and Ruth Gaspar, Diabetes Nurses and Specialist Educators from La Paz Hospital, Madrid, Spain.
  40. Lumber T. Tips for site rotation. When it comes to insulin, where you inject is just as important as how much and when. Diabetes Forecast. 2004; 57(7): 68–70.
  41. Thatcher G. Insulin injections. The case against random rotation. Am J Nurs. 1985; 85(6): 690–692.
  42. Spollett G, Edelman SV, Mehner P, et al. Improvement of insulin injection technique: examination of current issues and recommendations. Diabetes Educ. 2016; 42(4): 379–394.
  43. Baruah MP. Insulin pens: the modern delivery devices. J Assoc Physicians India. 2011; 59 Suppl: 38–40.
  44. Keith K, Nicholson D, Rogers D. Accuracy and precision of low-dose insulin administration using syringes, pen injectors, and a pump. Clin Pediatr (Phila). 2004; 43(1): 69–74.
  45. Kristensen CM, Donsmark M. Dose accuracy and durability of the NovoPen 4 insulin delivery device before and after simulation of 5 years of use and under various stress conditions. Clin Ther. 2009; 31(12): 2819–2823.
  46. Wielandt JO, Niemeyer M, Hansen MR, et al. FlexTouch: a prefilled insulin pen with a novel injection mechanism with consistent high accuracy at low- (1 U), medium- (40 U), and high- (80 U) dose settings. J Diabetes Sci Technol. 2011; 5(5): 1195–1199.
  47. Kalra S, Kalra B. Storage of insulin in rural areas. J Acad Med Sci. 2012; 2(2): 88–89.
  48. Kumar KM, Saboo B, Rao PV, et al. Type 1 diabetes: Awareness, management and challenges: Current scenario in India. Indian J Endocrinol Metab. 2015; 19(Suppl 1): S6–S8.
  49. Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016; 91(9): 1231–1255.
  50. Vimalavathini R, Gitanjali B. Effect of temperature on the potency & pharmacological action of insulin. Indian J Med Res. 2009; 130(2): 166–169.
  51. Mokta JK, Kalra S. Insulin storage in the Upper Himalayas. Rural Remote Health. 2014; 14(3): 2983.
  52. Herdman ML, Larck C, Schliesser SH, et al. Biological contamination of insulin pens in a hospital setting. Am J Health Syst Pharm. 2013; 70(14): 1244–1248.
  53. Kuehn BM. FDA warns against shared insulin pens. JAMA. 2009; 301(15): 1527.
  54. Institute for Safe Medication Practices. Reuse of insulin pen for multiple patients risks transmission of bloodborne disease. www.ismp.org/newsletters/acutecare/articles/20090212-2.asp.
  55. Centers for Disease Control and Prevention. Clinical reminder: insulin pens must never be used for more than one person. www.cdc.gov/injectionsafety/clinicalreminders/insulin-pens.html.
  56. Costello J, Parikh A. The sticking point: diabetic sharps disposal practices in the community. J Gen Intern Med. 2013; 28(7): 868–869.
  57. Govender D, Ross A. Sharps disposal practices among diabetic patients using insulin. S Afr Med J. 2012; 102(3 Pt 1): 163–164.
  58. Chaturvedi S, Arora NK, Lakshman M, et al. Study Group. Injection practices in India. South East Asia J Public Health. 2012; 1: 189–200.
  59. Kalra S, Balhara Y, Baruah M, et al. Addendum 2: forum for injection technique, India. Indian J Endocrinol Metab. 2014; 18(6): 800–803.
  60. Majumdar A, Sahoo J, Roy G, et al. Improper sharp disposal practices among diabetes patients in home care settings: Need for concern? Indian J Endocrinol Metab. 2015; 19(3): 420–425.
  61. Singh AP, Chapman RS. Knowledge, attitude and practices (KAP) on disposal of sharp waste, used for home management of type-2 diabetes mellitus in New Delhi, India. J Health Res. 2011; 25(3): 135–139.
  62. Tharkar S, Devarajan A, Barman H, et al. How far has translation of research been implemented into clinical practice in India? Are the recommended guidelines adhered to? Int J Diabetes Mellit. 2015; 3(1): 25–30.
  63. Chowdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ. 2003; 327(7411): 383–384.
  64. Johansson UB, Amsberg S, Hannerz L, et al. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care. 2005; 28(8): 2025–2027.
  65. Brady K, Avner JR, Khine H. Perception and attitude of providers toward pain and anxiety associated with pediatric vaccine injection. Clin Pediatr (Phila). 2011; 50(2): 140–143.
  66. Diamond S, Matok I. Pharmacists' anticipated pain compared to experienced pain associated with insulin pen injection and fingertip lancing. Canadian Journal of Diabetes. 2011; 35(3): 282–286.
  67. Heise T, Nosek L, Dellweg S, et al. Impact of injection speed and volume on perceived pain during subcutaneous injections into the abdomen and thigh: a single-centre, randomized controlled trial. Diabetes Obes Metab. 2014; 16(10): 971–976.
  68. Anderson G, Meyer D, Herrman CE, et al. Tolerability and safety of novel half milliliter formulation of glatiramer acetate for subcutaneous injection: an open-label, multicenter, randomized comparative study. J Neurol. 2010; 257(11): 1917–1923.
  69. Jørgensen JT, Rømsing J, Rasmussen M, et al. Pain assessment of subcutaneous injections. Ann Pharmacother. 1996; 30(7-8): 729–732.

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

 

Wydawcą serwisu jest  "Via Medica sp. z o.o." sp.k., ul. Świętokrzyska 73, 80–180 Gdańsk

tel.:+48 58 320 94 94, faks:+48 58 320 94 60, e-mail:  viamedica@viamedica.pl