New insulin injection and infusion recommendations for clinicians

Three articles appeared in the September print issue of the publication – with new research showing that many patients with diabetes are using insulin incorrectly and not getting the maximum benefit from this life-saving medication. Proper injection and infusion technique is critical to insulin’s consistent action and may be as important as the medication or diet and activity. These findings provide a clear roadmap for better clinical management of insulin use for people with diabetes and for their health care providers. 

The analysis of this landmark injection technique survey is the result of a BD (Becton, Dickinson and Company) sponsored international workshop known as the Forum for Injection Technique & Therapy Expert Recommendations (FITTER). This international congress included 183 diabetes experts from 54 countries and took place October 2015 in Rome.Two of the papers published in Mayo Clinic Proceedings address the key findings from this injection technique survey and a third paper presents the new insulin delivery recommendations,intended to help shape local and regional injection guidelines around the world.

Dr Kenneth Strauss, co-author and medical director, BD Europe stated: “FITTER and these publications set new standards for insulin delivery. Tools are embedded in these publications, which will allow patients and professionals to quickly translate them into everyday practice. If these recommendations become routine practice, we should soon see the improved outcomes that come from optimised insulin delivery.” Key findings of the insulin injection technique survey included:

• Many patients taking insulin are using needles that are longer and thicker than recommended, and are reusing the needles frequently. 
• One-third of those taking insulin have nodules or bumps in the fat tissue at their injection sites (a condition known as lipohypertrophy, or lipos). This is associated with incorrect rotation of injection sites and is also problematic with insulin infused via pumps. 
• If patients inject into lipos, the absorption of insulin is blunted and highly variable. This may cause patients to react by injecting more insulin, which puts them at risk of unexpected glucose swings and dangerous hypoglycemia
• Despite using more insulin, patients with lipos have worse glucose control, increasing their risk for eye, kidney and nerve complications. 

The third publication, ‘New Recommendations for Insulin Delivery’ is based on these survey findings as analysed by participants of the FITTER international congress. The new recommendations include:

• Use the shortest available pen needle (currently 4mm) or syringe needle (currently 6mm) for all injecting patients, regardless of age, sex or body size. 
• The shortest needle length is less painful, has higher patient acceptance and gives comparable glucose control
•  By contrast, excessively long needles increase a patient’s risk of intramuscular injections, which can accelerate insulin uptake and action, increasing glucose variability and risk of hypoglycemia
  
•  Correct rotation of injection sites can reduce the frequency of lipohypertrophy. Such reductions should improve glycaemic control and clinical outcomes, reduce insulin consumption and thereby lower health care costs.
• Limit use of pen needles and syringes to one-time, as reusing needles is not an optimal injection practice because they are no longer sterile after use. 

The new FITTER recommendations also contain important sections dealing with optimal insulin pump and infusion set guidance, as well as recommendations for use of safety-engineered injection devices for people who give injections, such as healthcare workers. In conclusion, adherence to these recommendations may lead to better injection and infusion experience for patients, safer injections by HCWs, and improved glucose control, which reduces the risk of long-term complications and saves health care funds. To review all of the studies in more detail and to view the “Golden Rules”, please visit: mayoclinicproceedings.org or http://www.fitter4diabetes.com.