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How injection “FIT” are your patients with diabetes?

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One of the best ways for you to help your patients with diabetes who are using injectable medications is to review their technique periodically to ensure they are getting the best outcome possible.

By Shelley Diamond, BScPhm

Illustration by Martin Bregman

The Canadian Forum on Injection Technique (FIT) was developed by a leading diabetes healthcare professional group as a result of concern regarding inadequate injection techniques for diabetes medications. The recommendations, launched in fall 2011, at the Canadian Diabetes Association Professional Conference, aim to:

– avoid intramuscular injections

– ensure healthy injection sites and

– provide clear and concise instructions to healthcare professionals regarding injection techniques.

Preparing for your patients for injection

  • In terms of psychological preparation, it is important to let your patients with type 2 diabetes know early on they will likely need injectable medication in the future. It is important for you to inform them that there is a progression of the disease and that it has nothing to do with their failing to manage it properly.
  • From a practical perspective, in terms of actual preparation, the recommendations state that disinfection of the injection site in the community setting is usually not required before injection. This will help reduce the cost of unnecessary alcohol wipes, which are not indicated in most situations.

Correct use of injectable devices

  • When using pen devices, priming of the device is required before every injection when administering insulin, however, for GLP-1 analogues, priming is only required the first time the device is used. This is based on the different designs of each pen.
  • In terms of pen needles, it is important to tell your patients that the pen needle should be used only once in order to reduce the risk of lipohypertrophy and to ensure the delivery of the correct dose.
  • Regardless of BMI, a needle length of 4, 5 and 6 mm is suitable for all people with diabetes. Research does not support the use of needles larger than 8mm and they increase the chance of giving an intramuscular injection. For most people using needles ranging from 4-6mm, a skin lift is not needed and injection should be at a 90 degree angle. For slim people, a skin lift and an injection at 45 degree angle may be more appropriate.

Selection of injection site

  • The abdomen is the preferred injection site, however, the thighs and buttocks are alternatives. Remind your patients that rotation of injection sites is essential within an anatomical area to avoid lipohypertrophy. Before injection, your patients should inspect and palpate the site, and a healthcare professional should check these sites at every visit.

Physical aspects of insulin

  • Although temperature does not affect the pharmacokinetics, injecting insulin at room temperature rather than refrigerated may reduce burning, irritation or painful injections, and also helps to facilitate the re-suspension of cloudy preparations.  Make sure you remind those using cloudy insulin (i.e. NPH and pre-mixed insulins) to roll it gently 10 times, followed by tipping (not shaking) it 10 times, and visually check it to ensure the suspension has a consistent milky-white appearance.

Special populations

  • For women who are pregnant, the abdomen remains the preferred injection site and the umbilicus and areas of taut skin should be avoided.
  • For elderly patients, it is important to assess their cognitive and functional abilities to ensure it is safe for them to self-inject.
  • When dealing with children, if there is concern they may be underdosing or overdosing and to ensure appropriate site rotation, injections should be closely supervised by a parent until children are able to manage on their own.

By adopting these injection principles in your daily practice, FIT will be able to say they have accomplished their vision of helping those using injectable therapies to achieve the best health outcomes by ensuring each dose is delivered to the right injection site using the right technique.

Shelley Diamond BScPhm is the president of Pedipharm Consultants and Diabetes Care Community Inc. (www.diabetescarecommunity.ca)