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Gupta S, Ramteke H, Gupta S, Gupta S, Gupta KS. Are People With Type 1 Diabetes Mellitus Appropriately Following Insulin Injection Technique Practices: A Review of Literature. Cureus 2024; 16:e51494. [PMID: 38304656 PMCID: PMC10831209 DOI: 10.7759/cureus.51494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/01/2024] [Indexed: 02/03/2024] Open
Abstract
People with type 1 diabetes mellitus (T1DM) need to take multiple doses of insulin injections daily throughout their lives. However, a notable portion of people with diabetes mellitus (DM) show suboptimal insulin injection technique practices. They are supposed to follow the recommended insulin injection technique guidelines. Our explorative literature search, including studies from the past 30 years, is expected to identify the deficiencies of self-injection insulin techniques and the associated complications in people with T1DM, where we have summarised the overall incidence of complications that have occurred due to nonadherence of the prescribed guidelines, along with their associated risk factors. We have attempted to include multiple systematic reviews, meta-analyses, literature reviews, case reports, and original articles from the search engines and databases like PubMed, Scopus, ScienceDirect, Cochrane Library, Google Scholar, and BioMed Central, and studies with only human participants were included in this search. The knowledge sharing from this research may be utilised for enhancing the structured education diabetes programme and implementing the population-based corrective measures, including the thrust areas in future multi-centre longitudinal research studies and recommendations, which can prevent unnecessary complications and enhance their quality of life. Correct insulin administration technique, abstaining from administration of injection at the areas with lipohypertrophy, rotation of injection sites, and ultrasound scanning can be used as a complimentary method to detect the lipohypertrophy at an early stage. Liposuction is beneficial in reducing the extensive lipohypertrophic tissues but helps achieve only cosmetically satisfactory outcome; thus, empowering people to follow insulin injection technique guidelines is one of the best strategies to reduce the high prevalence of lipohypertrophy. To conclude, education among the people with DM, especially T1DM who have to take insulin regularly, needs to be carried out consistently in the clinical settings, to prevent the severe complications caused due to inappropriate insulin injection techniques.
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Affiliation(s)
- Swar Gupta
- Medicine and Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshal Ramteke
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shlok Gupta
- Internal Medicine, Sunil's Diabetes Care n' Research Centre, Nagpur, IND
| | - Sunil Gupta
- Diabetology, Sunil's Diabetes Care n' Research Centre, Nagpur, IND
| | - Kavita S Gupta
- Nutrition, Sunil's Diabetes Care n' Research Centre, Nagpur, IND
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KALAN SARI I, DEMİRCİ H. Impact of patient satisfaction with insulin pens on glycemic control. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1076784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim: Adherence to the insulin regimen is poor. The use of an insulin pen contributes positively to glycemic control by increasing patient satisfaction and adherence. The aim of this study is to analyze the influence of patients' opinions of insulin pen use on glycemic control in type 2 diabetes mellitus (T2DM).
Material and Method: 126 patients with T2DM who use insulin and inject it with insulin pens were included in the study. Patients' evaluations about the pens (ergonomics, ease of reading the dosage scale, dose selection, needle change, and ease of use of the insulin pen in general) were assessed. Glycemic parameters, demographic characteristics, and treatment protocol were recorded.
Results: Patients who perceived the use of the insulin pen as ergonomically 'excellent’ had a significantly lower HbA1c (8.0±1.4%) (p=0.04). HbA1c was significantly lower in patients who perceived needle tip replacement as ‘very easy’ (8.0±1.6%) (p=0.04). No statistically significant relationship was found between the ease of reading the dosage scale and the HbA1c value (p=0.53). The HbA1c value decreased significantly in patients who rated the dosage selection as 'very easy' (8.1±1.7%) (p=0.02). The HbA1c value increased significantly in patients who rated the pen as ‘difficult’ to use (12.2±1.6%) (p=0.01).
Conclusion: In our study, we found that patients' opinions of insulin pen use may influence glycemic control parameters. HbA1c was better in patients who found the insulin pen as easy to use and good in ergonomics. In T2DM, patient assessment of insulin pen injection is related to glycemic control. New studies are needed to say whether this situation is related to the appropriate dose of insulin injection or adherence to therapy.
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Leohr JK, Dellva MA, LaBell E, Coutant DE, Linnebjerg H. Evaluation of the Pharmacokinetic Profile of Ultra Rapid Lispro Administered Subcutaneously at Different Injection Sites. Clin Ther 2022; 44:836-847. [DOI: 10.1016/j.clinthera.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/15/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
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Ucieklak D, Mrozinska S, Wojnarska A, Malecki MT, Klupa T, Matejko B. Insulin-induced Lipohypertrophy in Patients with Type 1 Diabetes Mellitus Treated with an Insulin Pump. Int J Endocrinol 2022; 2022:9169296. [PMID: 35111222 PMCID: PMC8803446 DOI: 10.1155/2022/9169296] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lipohypertrophy (LH) of subcutaneous tissue is an insulin-induced complication occurring in patients with diabetes. We aimed to define the prevalence of LH and identify its risk factors in type 1 diabetes (T1DM) patients treated with continuous subcutaneous insulin infusion (CSII). MATERIALS AND METHODS The study included 79 consecutive CSII-treated T1DM patients. The diagnose of LH was based on ultrasonography (US) as a reference method, physical examination was also performed. Clinical characteristics were available from the medical records. RESULTS The median age of patients was 28 years (interquartile range [IQR], 24-30.5) with a body mass index (BMI) of 24.5 ± 3.5 kg/m2, HbA1c 7.1% (IQR, 6.7-8.1), T1DM duration 15 (9-20) years, and CSII use duration of 8 year (IQR, 5-11). LH was detected by US in 75 (94.9%) patients. This value was much higher than this obtained by visual assessment (n = 39, 49.4%) or palpation (n = 59, 74.7%). In univariate analyses, the following risk factors for occurrence of 5 and more LH lesions were identified: the ratio of insulin dose to body mass exceeding 0.7 IU/kg (OR, 3.69; 95% CI, 1.43-10.01) and the total daily insulin dose (OR, 1.05; 95% CI, 1.02-1.09). A higher dose of insulin per kg remained a significant risk factor of LH amount in multivariate analysis. CONCLUSION This selected T1DM cohort treated with CSII had a very high prevalence of LH. US assessment should be considered as a reference method for LH screening in T1DM patients. The identified risk factors for the number of LH lesions were related to insulin dosing.
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Affiliation(s)
- Damian Ucieklak
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Sandra Mrozinska
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Aleksandra Wojnarska
- University Hospital, Krakow, Poland
- Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T. Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Bartłomiej Matejko
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
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Bochanen N, Decochez K, Heleu E, Cuypers J, Vercammen C, Coremans P, Vanhaverbeke G, Shadid S, Keymeulen B, Bolsens N, De Block C. Lipohypertrophy Monitoring Study (LIMO): Effect of single use of 4 mm pen needles combined with education on injection site rotation on glycaemic control: Confirmation of an unpleasant truth. Diabet Med 2022; 39:e14672. [PMID: 34407260 DOI: 10.1111/dme.14672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022]
Abstract
AIMS To investigate whether single use of 4 mm needles combined with education about injection technique and lipohypertrophy affects HbA1c, hypoglycaemia and glucose variability. METHODS Insulin-injecting people with diabetes recruited from nine Belgian diabetes centres were prospectively followed for 6 months. They were provided 4 mm pen needles and education concerning injection technique using an online platform (BD and Me™) based on the international Forum for Injection Technique & Therapy Recommendations focused on avoidance of lipohypertrophy zones and reduction of needle reuse. RESULTS A total of 171 people with diabetes were included of which 146 completed the study. At baseline, lipohypertrophy was present in 63.0% of those who completed the study, with 51.4% injecting in zones of lipohypertrophy, 37.0% incorrectly rotating and 95.9% reusing needles. After the intervention, 7.5% still injected in a lipohypertrophy zone, 4.1% rotated incorrectly and needle reuse decreased to 21.2%. The number of participants with severe hypoglycaemias (from 15.8% to 4.1%, p < 0.001), unexplained hypoglycaemias (from 46.6% to 16.4%, p < 0.001) and high glucose variability (from 64.4% to 29.5%, p < 0.001) was significantly reduced. HbA1c and total daily insulin dose remained stable. CONCLUSION The combination of 4 mm pen needles and online education on injection techniques significantly reduced the number of people with severe hypoglycaemic episodes, unexplained hypoglycaemia and high glucose variability but did not improve HbA1c control nor lower insulin needs. TRIAL REGISTRATION ClinicalTrials.gov NCT04659330.
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Affiliation(s)
- Niels Bochanen
- Department of Endocrinology-Diabetology-Metabolism, Antwerp University Hospital, Edegem, Belgium
| | - Katelijn Decochez
- Department of Endocrinology-Diabetology, AZ Jan Portaels, Vilvoorde, Belgium
| | - Els Heleu
- Department of Endocrinology-Diabetology, AZ Jan Portaels, Vilvoorde, Belgium
| | - Joke Cuypers
- Department of Endocrinology-Diabetology, AZ Turnhout, Turnhout, Belgium
| | - Chris Vercammen
- Department of Endocrinology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Peter Coremans
- Department of Endocrinology-Diabetology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Gerd Vanhaverbeke
- Department of Endocrinology-Diabetology, AZ Groeninge, Kortrijk, Belgium
| | - Samyah Shadid
- Department of Endocrinology-Diabetology, University Hospital Ghent, Ghent, Belgium
| | - Bart Keymeulen
- Department of Diabetology, University Hospital Brussels VUB, Jette, Belgium
| | - Nancy Bolsens
- Department of Endocrinology-Diabetology-Metabolism, Antwerp University Hospital, Edegem, Belgium
| | - Christophe De Block
- Department of Endocrinology-Diabetology-Metabolism, Antwerp University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, Belgium
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Demir G, Er E, Atik Aktınok Y, Özen S, Darcan Ş, Gökşen D. Local complications of insulin administration sites and effect on diabetes management. J Clin Nurs 2021; 31:2530-2538. [PMID: 34622517 DOI: 10.1111/jocn.16071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Administration of insulin may be associated with substantial cutaneous adverse effects, such as lipoatrophy and lipohypertrophy (LH), which can cause glycemic excursions above and below the target levels for blood glucose. Our aim was to evaluate the effect on compliance with the use of insulin administration site, dermatological complications and diabetes management in children with type 1 diabetes (T1D). METHODS Patients aged 0 - 21 years who were followed up with the diagnosis of T1D for at least one year were included. A 14-question survey including demographic characteristics and a subjective opinion of skin-related complications of insulin administration was given. Data were obtained from the medical records to evaluate the effect of dermatological complications on diabetes management. This study was checked with the STROBE checklist. RESULTS Two hundred and fifty-four patients were included and 53% of these were female. The mean age was 14.9 ± 4.7 years and the duration of T1D was 7.3 ± 4.1 years. The mean HbA1c level was 8 ± 1.4% and the mean total insulin dose was 0.84 ± 0.25 units/kg/day. More than half of the individuals (57%) were receiving multiple daily injections (MDI) and 43% were on insulin pump therapy (IPT). Of the participants, 11.8% reported LH, 7.5% wound, 21.7% allergy, 55.5% bleeding, 41.3% bruising and 47.2% pain. LH rates varied significantly by regimen, 17.1% in MDI and 4.6% with IPT (p = .001). Those with LH were using higher median doses of insulin (0.97 U/kg/day) than those who did not (0.78 U/kg/day; p = .016). LH was reported more frequently (18.3%) in patients with frequent hypoglycemia (p = .007). Positive correlation between BMI-SDS and LH in patients aged <18 years was found (p = .043). LH rates by site were: right arm 20.8%, left arm 26.4%, right abdomen 26.4%, left abdomen 22.6% and 1% in the right and left leg. CONCLUSIONS Local complications of insulin therapy are common in young patients with T1D. The complication with the most impact on metabolic control was LH, present in nearly 12% of patients. Users of IPT have a significantly lower risk of LH. The results emphasise the importance of individualised education for young T1D patients and their families about injection site preference and rotation techniques. RELEVANCE TO CLINICAL PRACTICE The diabetes team should check the insulin administration sites of children with type 1 diabetes at each visit and provide repeated education about the dermatological complications of insulin.
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Affiliation(s)
- Günay Demir
- Division of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Ege University, İzmir, Turkey
| | - Eren Er
- Division of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Ege University, İzmir, Turkey
| | - Yasemin Atik Aktınok
- Division of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Ege University, İzmir, Turkey
| | - Samim Özen
- Division of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Ege University, İzmir, Turkey
| | - Şükran Darcan
- Division of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Ege University, İzmir, Turkey
| | - Damla Gökşen
- Division of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Ege University, İzmir, Turkey
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Wang K, Zhang S, Liu C, Chen Y. A meta-analysis and meta-regression on the prevalence of lipohypertrophy in diabetic patients on insulin therapy. Therapie 2021; 76:617-628. [PMID: 33958198 DOI: 10.1016/j.therap.2021.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/14/2021] [Accepted: 04/06/2021] [Indexed: 12/16/2022]
Abstract
AIMS OF THE STUDY This study aimed to assess the prevalence of lipohypertrophy (LH) in diabetes mellitus (DM) patients on insulin therapy and identify factors influencing the prevalence rates through a meta-analysis and meta-regression. METHODS Databases of PubMed, Embase, Scopus, and Google Scholar were screened from inception to 20th Aug 2020. Data on prevalence was transformed using the logit transformation for pooling the proportions using the DerSimonian-Laird meta-analysis model. Random-effects meta-regression analysis was performed to assess the influence of the following moderators on the pooled prevalence: male gender, mean age, type of DM, DM duration, duration of insulin therapy, needle re-users, rotation of injection site, HbA1c, insulin dose, ≥8mm needle users and mean number of injections/day. RESULTS Forty-five studies were included. LH was diagnosed by observation and palpation by all studies. On meta-analysis of data from 26,865 participants, the overall prevalence of LH was found to be 41.8% (95% CI: 35.9% to 47.6%). On region-wise analysis, pooled prevalence of LH in Europe was 44.6% (95% CI: 37.5% to 51.8%) in Africa was 34.8% (95% CI: 16.9% to 52.8%) and in Asia was 41.3% (95% CI: 27.2% to 55.3%). The pooled prevalence of LH in studies only on type 1 and type 2 DM patients was 39.9% (95% CI: 28.3% to 51.6%) and 45.9% (95% CI: 29.5% to 62.4%) respectively. Only insulin duration was found to significantly influence the prevalence of LH on meta-regression. CONCLUSION Our study indicates that the prevalence of LH in DM patients on insulin therapy is estimated to be 41.8%. The longer the duration of insulin therapy, the higher is the prevalence of LH.
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Affiliation(s)
- Ke Wang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China; Yancheng First Hospital, Affiliated Hospital of Nanjing University Medical School, The First People's Hospital of Yancheng, 210028 Nanjing, Jiangsu, P.R. China
| | - Shaohong Zhang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China
| | - Chao Liu
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China.
| | - Yan Chen
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China
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Factors That Affect Symptoms of Injection Site Infection among Japanese Patients Who Self-Inject Insulin for Diabetes. Healthcare (Basel) 2021; 9:healthcare9040402. [PMID: 33916158 PMCID: PMC8066722 DOI: 10.3390/healthcare9040402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
In Japan, skin disinfection is typically considered necessary before an insulin injection to prevent infection at the injection site. This cross-sectional study evaluated factors that influenced symptoms of injection site infection among 238 Japanese patients who self-injected insulin for diabetes between October 2015 and January 2016. A structured questionnaire was used to collect data regarding skin disinfection practices, infection symptoms at the injection site, frequency of injections, environment at the time of injection, and hygiene habits. The majority of patients (83.2%) performed skin disinfection before the self-injection. Logistic regression analysis revealed that infection at the injection site was positively associated with skin disinfection before injection, age, and performing injections outside home. It was speculated that omitting skin disinfection before administering subcutaneous insulin injection was not the factor that affected the symptoms of injection site infection. The greatest contributor to infection symptoms was injections performed outside the home. Future studies focusing on the environment, in which patients administer insulin injections, to assess its influence on symptoms of injection site infections are warranted.
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Romano C, Alfrone C, Lmberti C, Strollo F. Bruising: A Neglected, Though Patient-Relevant Complication of Insulin Injections Coming to Light from a Real-Life Nationwide Survey. Diabetes Ther 2021; 12:1143-1157. [PMID: 33687646 PMCID: PMC7994491 DOI: 10.1007/s13300-021-01026-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/08/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Despite the availability of sophisticated devices and suitable recommendations on how to best perform insulin injections, lipohypertrophy (LH) and bruising (BR) frequently occur as a consequence of improper injection technique. AIM The purpose of this nationwide survey was to check literature-reported LH risk factors or consequences for any association with BR METHOD: This was a cross-sectional, observational, multicenter study based on the identification of skin lesions at all patient-reported insulin injection sites in 790 subjects with diabetes. General and injection habit-related elements were investigated as possible BR risk factors. RESULTS While confirming the close relationship existing between LH and a full series of factors including missed injection site rotation, needle reuse, long-standing insulin treatment, frequent hypoglycemic events (hypos), and great glycemic variability (GV), the observed data could find no such association with BR, which anyhow came with high HbA1c levels, missed injection site rotation, and long-standing insulin treatment. CONCLUSION BR most likely depends on the patient's habit of pressing the injection pen hard onto the skin. Despite being worrisome and affecting quality of life, BR seems to represent a preliminary stage of LH but does not affect the rate of hypos and GV. TRIAL REGISTRATION 207/19.09.2017.
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Affiliation(s)
- Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy.
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy.
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Teresa Della Corte
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Carmine Romano
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | | | - Clelia Lmberti
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy
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Chen L, Xing Q, Li J, Zhou J, Yuan Y, Wan Y, Pflug BK, Strauss KW, Hirsch LJ. Injection Technique Education in Patients with Diabetes Injecting Insulin into Areas of Lipohypertrophy: A Randomized Controlled Trial. Diabetes Ther 2021; 12:813-826. [PMID: 33570716 PMCID: PMC7947164 DOI: 10.1007/s13300-021-01013-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/25/2021] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION The aim of this randomized controlled trial was to assess the impact of providing intensive injection technique (IT) education to patients routinely injecting insulin into sites of lipohypertrophy (LH). METHODS Between November 2016 and May 2018, insulin-injecting patients with LH treated at Tianjin Metabolism Hospital (a public tertiary medical institution), Tianjin, China, were included in a 6-month prospective randomized controlled trial and randomized into either the intervention (the IT-education group) or the control (control group) arm. The control and IT-education groups were seen by different groups of trained nurses on different clinic days. IT education emphasized moving injections to normal tissue sites, within-and between-site injection rotation, an initial reduction of insulin total daily dose (TDD), and stopping needle reuse. Needles were provided to the IT group, while controls acquired needles in their usual way. Differences in changes in glycated hemoglobin (HbA1c) and insulin TDD were the primary and main secondary endpoints, respectively. RESULTS The control (n = 104) and IT-education (N = 106) groups had similar demographic parameters (97% with type 2 diabetes) and baseline IT behavior. HbA1c reduction was similar in the IT-education and control group in the intention-to-treat (ITT) analysis (6-month between-group difference 0.16% [1.7 mmol/mol], 95% confidence interval [CI] - 0.11, 0.43 [- 1.2, 4.7]; p = 0.239) but was significant by the per-protocol (PP) analysis (difference 0.31% [3.4 mmol/mol], 95% CI 0.02, 0.60 [0.2, 6.6]; p = 0.038). Changes in TDD insulin in the IT-education group were approximately - 7 and - 8 IU by the ITT and PP analyses, respectively, versus - 1 IU (nonsignificant) in the controls (both between-group differences p ≤ 0.05). Despite the study design, IT education "contamination" (unplanned adoption of IT-intervention behaviors) was documented in 63 control patients. By post hoc analyses, HbA1c in "contaminated" controls decreased by 0.70% (7.7 mmol/mol) vs. 0.20% (2.2 mmol/mol) in "non-contaminated' patients (p = 0.019) at 6 months. CONCLUSIONS Proper IT, including learning to not inject into sites of LH, proper within- and between site rotation, needle reuse reduction, and the use of 4-mm, 32-G needles in Chinese patients injecting into sites of LH enables a safe reduction of TDD insulin while maintaining overall glycemic control. TRIAL REGISTRATION Trial registration: ChiCTR-IOR-16009270 in the Chinese Clinical Trials Registry.
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Affiliation(s)
- Liming Chen
- NHC Key Laboratory of Hormone and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China.
| | - Qiuling Xing
- NHC Key Laboratory of Hormone and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Jing Li
- NHC Key Laboratory of Hormone and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Jianxin Zhou
- NHC Key Laboratory of Hormone and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Yi Yuan
- Medical Affairs, Becton Dickinson and Company, Inc., Shanghai, China
| | - Ying Wan
- Diabetes Care, Becton Dickinson and Company, Inc., Franklin Lakes, NJ, USA
| | - Brian K Pflug
- Diabetes Care, Becton Dickinson and Company, Inc., Franklin Lakes, NJ, USA
| | - Kenneth W Strauss
- Former Global Medical Affairs, BD Diabetes Care, Becton Dickinson and Company, Inc., Erembodegem, Belgium
| | - Laurence J Hirsch
- Former Global Medical Affairs, BD Diabetes Care, Becton Dickinson and Company, Inc., Franklin Lakes, NJ, 07417, USA
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Nasir BB, Buseir MS, Muhammed OS. Knowledge, attitude and practice towards insulin self-administration and associated factors among diabetic patients at Zewditu Memorial Hospital, Ethiopia. PLoS One 2021; 16:e0246741. [PMID: 33556090 PMCID: PMC7870072 DOI: 10.1371/journal.pone.0246741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 01/25/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diabetes mellitus is a common health problem worldwide. Proper insulin administration plays an important role in long term optimal blood sugar control. Adequate knowledge and attitude about insulin self-administration could also improve the management of diabetes and eventually improve the quality of life. This study aimed to assess knowledge, attitude and practice towards insulin self-administration and associated factors among diabetic patients at Zewditu Memorial Hospital (ZMH), Ethiopia. METHODS An institution-based cross-sectional study was conducted among 245 diabetic patients who were selected by systematic random sampling during follow-up at ZMH. The data was collected using an interviewer-administered structured questionnaire and analyzed by SPSS v.20. Binary logistic regression was used to identify associated factors of patients' knowledge and P < 0.05 was used to declare the association. RESULTS Among 245 patients enrolled, 53.9% were male with a mean age of 53.26 ±13.43 years and more than 84% of the patients can read and write. The overall patients' knowledge was 63.4%. Better knowledge was observed concerning timing (78.4%) and site of insulin injection (89.4%), while knowledge on the angle of inclination during insulin administration (43.3%) and complications of insulin therapy (49%) were low. Patients who were male gender, never married, government or NGO employees, urban residents, who completed elementary and higher education had a higher knowledge than their comparators. The majority (62%) of the study patients had a favorable attitude on insulin self-administration. Although the majority 177(72.2%) of the study patients have administered insulin themselves, only 120(49.0%) of the patients injected insulin appropriately at 450. Frequent repetition of the injection site was practiced among 176(71.8%) patients and 139(56.7%) injected insulin before or immediately after food intake. CONCLUSION Patients' knowledge and attitude seem suboptimal and malpractice of insulin self-administration was reported. Therefore, the gaps should be addressed through patient education and demonstration of insulin injection during each hospital visit.
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Affiliation(s)
- Beshir Bedru Nasir
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Miftah Shafi Buseir
- Department of Pharmacy, College of Health Sciences, Mizan-Tepi University, Tepi, Ethiopia
| | - Oumer Sada Muhammed
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Tsadik AG, Gidey MT, Assefa BT, Abraha HN, Kassa TD, Atey TM, Feyissa M. Insulin injection practices among youngsters with diabetes in Tikur Anbesa Specialized Hospital, Ethiopia. J Diabetes Metab Disord 2021; 19:805-812. [PMID: 33520804 DOI: 10.1007/s40200-020-00565-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/02/2020] [Indexed: 11/29/2022]
Abstract
Purpose The main aim of this study was to explore how participants were practicing insulin injections and assess its association with the insulin related-outcomes. Methods A hospital-based cross-sectional study was conducted among 176 youngsters with diabetes in Tikur Anbesa Specialized Hospital, Ethiopia. The inclusion criterion was the use of insulin treatment for a minimum of one year. Data about insulin injection practices was derived from participants' report. Descriptive statistics was presented using frequency distributions and percentages for categorical variables while measure of central tendencies and dispersion for continuous variables. Chi-square test was employed to test for the association between compared variables. Results Participants were asked on how frequent they practice the appropriate insulin injecting practices. Based on that, eliminating air bubbles from a syringe, lifting skin fold during an injection, inserting a needle deep enough in the subcutaneous tissue, inspecting injection sites and self-monitoring of blood glucose were frequently done practices in more than 80% of the participants. Besides, over half of the participants reported that they frequently practice; insulin vial inspection, physical exercise, inject 1-3 cm apart from previous site, and insert a needle at 450. Regarding insulin storage, more than half of them store opened insulin in the refrigerator, though it is advisable to store it at room temperature. Appropriate injection site rotation was reported by nearly one-third of the participants. Questions such as; gentle re-suspension of cloudy insulin, adjust insulin dose when necessary and change insulin syringe at every injection were reported by very few of the participants. Coming to glycemic control of our study subjects, 83% of them had HgbA1C of above 7.5% (non-optimal) and 31% reported at least one episode of hypoglycemia. Non-optimal glycemic control was explained by poor injection site hygiene (p < 0.038) and infrequent inspection of injection sites (p < 0.049). Conclusion Compared to previous studies, this study came with higher proportion of participants who frequently practice the appropriate insulin injection practices. However, it is still important to educate patients on some crucial injecting practices.
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Affiliation(s)
- Afewerki Gebremeskel Tsadik
- Clinical Pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Meles Tekie Gidey
- Pharmacoepidemiology and Social pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Brhane Teklebrhan Assefa
- Department of Pharmacology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Haftom Niguse Abraha
- Clinical Pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Tesfaye Dessale Kassa
- Clinical Pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Tesfay Mehari Atey
- Clinical Pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Mamo Feyissa
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Lipohypertrophy in insulin injecting patients with diabetes mellitus: an under-recognized barrier for glycemic control. Int J Diabetes Dev Ctries 2020. [DOI: 10.1007/s13410-020-00889-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Bari B, Corbeil MA, Farooqui H, Menzies S, Pflug B, Smith BK, Vasquez A, Berard L. Insulin Injection Practices in a Population of Canadians with Diabetes: An Observational Study. Diabetes Ther 2020; 11:2595-2609. [PMID: 32893337 PMCID: PMC7475025 DOI: 10.1007/s13300-020-00913-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Proper insulin injection technique has demonstrated positive clinical outcomes in patients with diabetes. A Canadian-based practice reflective was undertaken to evaluate the current state of understanding of injection technique practices by patients administering insulin, and the importance physicians place on proper injection technique. METHODS Twenty-four sites across Canada completed a practice profile survey and enrolled adult non-pregnant patients with either type 1 or type 2 diabetes injecting insulin using an insulin pen. Seven areas of proper injection technique to be evaluated were identified by the study steering committee: size of injection site, use of a skin lift, needle reuse, length of the needle, duration of the needle in the skin, injection into lipohypertrophic tissue, and applied injection force. During a scheduled visit, each patient filled out the Injection Technique Survey and the physician documented the answers via an electronic database. RESULTS Almost all physicians surveyed agreed (96%) that proper insulin injection technique is important or very important and 80% indicated they were either completely confident or fairly confident in discussing overall insulin injection technique. All patients surveyed were making at least one insulin injection technique error within the following categories: applied injection force (76%), area size of injection site (64%), duration of pen needle in skin (61%), pen needle reuse (39%), performs a skin lift with a 4 or 5 mm needle (38%), uses a longer pen needle than required (34%), and injection of insulin into lipohypertrophic tissue (37%). CONCLUSION Patients commonly make insulin injection errors. Patient and physician education on optimal insulin injection technique continues to be an unmet medical need for the treatment of patients with diabetes. Prospective trials examining the impact of new technology, diabetes educational teams, and e-learning as educational interventions are potential avenues to explore in future studies to support improved insulin injection technique.
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Affiliation(s)
- Basel Bari
- Markham HealthPlex Medical Centre, Markham, ON, Canada
| | | | - Hena Farooqui
- Medical Division, CTC Communications, Mississauga, ON, Canada
| | - Stuart Menzies
- Medical Division, CTC Communications, Mississauga, ON, Canada
| | - Brian Pflug
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Brennan K Smith
- Medical Division, CTC Communications, Mississauga, ON, Canada
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Gentile S, Guarino G, Corte TD, Marino G, Fusco A, Corigliano G, Colarusso S, Piscopo M, Improta MR, Corigliano M, MartedÌ E, Oliva D, Russo V, Simonetti R, Satta E, Romano C, Alfarone C, Vetrano A, Martino C, Lamberti C, Vecchiato A, Cozzolino G, Brancario C, Strollo F. Insulin-Induced Skin Lipohypertrophy in Type 2 Diabetes: a Multicenter Regional Survey in Southern Italy. Diabetes Ther 2020; 11:2001-2017. [PMID: 32683659 PMCID: PMC7435140 DOI: 10.1007/s13300-020-00876-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Lipohypertrophies (LHs) due to incorrect insulin injection techniques have been described in the literature for decades. Their rate averages 38%, but this is still controversial because of the vast range reported by different publications, most of which fail to describe the selected detection protocol and therefore are not entirely reliable. We still need to identify the real LH rate, and only consistently using a standardized method in a large cohort of insulin-treated (IT) patients make this possible. METHODS Our group performed thorough clinical skin examinations on patients suffering from type 2 diabetes mellitus (T2DM): 1247 IT T2DM outpatients were examined according to a standardized protocol, previously published elsewhere, as well as an ultrasound scan of the same skin areas to assess the degree of concordance between the two methods and to evaluate the demographic, clinical, and behavioral risk factors (RF) as well as metabolic consequences of identified LHs. RESULTS The concordance between the two methods was 99%. Identified risk factors for LHs were needle reuse, failure to rotate injection sites, and ice-cold insulin injections. High HbA1c values, wide glycemic variability, and longstanding proneness to hypoglycemia with a high rate of ongoing hypoglycemic events proved to be significantly associated with LHs, too; the same applied to cardiovascular and renal complications as well as to living alone and being retired. CONCLUSIONS Based on a strict well-structured methodology, our data confirmed what has already been reported in the literature on factors leading to, or associated with, LHs and, for the first time in adults, indicated cryotrauma from ice-cold insulin injections and specific social conditions as factors facilitating LH occurrence. HCPs should therefore plan a yearly clinical examination of all injection sites to improve patient quality of life through better glucose control and a reduced rate of hypoglycemic events. TRIAL REGISTRATION Trial registration no. 127-11.01.2019, approved by the Scientific and Ethics Committee of Campania University "Luigi Vanvitelli," Naples, Italy.
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Affiliation(s)
- Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy.
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy.
- Nefrocenter Research and Nyx Start-Up, Naples, Italy.
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy
| | - Teresa Della Corte
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
- Diabetes Unit AID Portici, Portici, Italy
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy
| | | | | | | | | | - Maria Rosaria Improta
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
- Diabetes Unit AID Portici, Portici, Italy
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Marco Corigliano
- Diabetes Unit AID Napoli, Napoli, Italy
- Diabetes Unit AID Benevento, Benevento, Italy
- Diabetes Unit AID Nola, Nola, Italy
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
- Diabetes Unit AID Portici, Portici, Italy
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | | | - Domenica Oliva
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | | | | | - Ersilia Satta
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | | | | | | | - Carmine Martino
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
| | - Clelia Lamberti
- Diabetes Unit, AID Nocera Inferiore, Nocera Inferiore, Italy
| | | | | | | | - Felice Strollo
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
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Pager A, Combedazou A, Guerrero K, Tzvetkova-Chevolleau T, Morel D, Frolet C, Glezer S. User experience for manual injection of 2 mL viscous solutions is enhanced by a new prefillable syringe with a staked 8 mm ultra-thin wall needle. Expert Opin Drug Deliv 2020; 17:1485-1498. [PMID: 32700596 DOI: 10.1080/17425247.2020.1796630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES User experience was compared between a new pre-fillable 2.25 mL glass syringe equipped with an ultra-thin-wall (UTW) 8 mm staked needle and a marketed BD Neopak™ syringe equipped with a special-thin-wall (STW) 12.7 mm staked needle. METHODS Participants simulated subcutaneous injections with both syringes alone (formative Human Factors study) and in combination with a needlestick-prevention device (validation Human Factors study). RESULTS Usability results of both studies showed higher success rates for delivering the full dose of 2 mL viscous solution (30 cP) with the 8mmUTW syringe than with the 12.7mmSTW one (63% vs. 42% in the formative study). The use of the 8mmUTW syringe demonstrated also better ease of use and acceptance results and 72% of formative study participants preferred this new syringe over the current one when delivering the viscous solution. Using a shorter needle also showed a benefit in decreasing the injection-related anxiety. Besides, in the case of a non-recommended injection technique, the calculated risk of accidental intramuscular injection is reduced by 2 to 13 times with the 8mmUTW syringe. CONCLUSION Altogether, the results obtained demonstrated an improvement of the user experience with this new syringe compared to the current one in the manual delivery of 2 mL viscous solutions.
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Affiliation(s)
- Aurélie Pager
- BD Medical - Pharmaceutical Systems, Becton Dickinson and Company , Le Pont De Claix, France
| | - Anne Combedazou
- BD Medical - Pharmaceutical Systems, Becton Dickinson and Company , Le Pont De Claix, France
| | - Karen Guerrero
- BD Medical - Pharmaceutical Systems, Becton Dickinson and Company , Le Pont De Claix, France
| | | | - Didier Morel
- Global Clinical Development, Becton Dickinson and Company , Le Pont De Claix, France
| | - Cécile Frolet
- BD Medical - Pharmaceutical Systems, Becton Dickinson and Company , Le Pont De Claix, France
| | - Stanislav Glezer
- Diabetes Care, Becton Dickinson and Company , Franklin Lakes, NJ, USA
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Perceptions of Insulin Pen Use and Technique in Black and Hispanic/Latino Patients with Type 2 Diabetes: a Qualitative Study. J Racial Ethn Health Disparities 2020; 7:949-957. [DOI: 10.1007/s40615-020-00718-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 10/09/2019] [Accepted: 02/02/2020] [Indexed: 01/09/2023]
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Improved insulin injection technique, treatment satisfaction and glycemic control: Results from a large cohort education study. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2020; 19:100217. [PMID: 32071879 PMCID: PMC7013331 DOI: 10.1016/j.jcte.2020.100217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023]
Abstract
The efficacy of insulin therapy in diabetes depends on proper injection technique. Professional education can results in higher patients’ satisfaction. Proper insulin injection is important to good glycemic control.
Objective The aim of this study was to elucidate injection techniques, treatment satisfaction and glycemic control after education among patients with type 2 diabetes. Methods 4513 insulin-treated diabetic patients enrolled in the observational study EGIDA II (Education and GensuPen In Diabetology II) filled out the questionnaire which focused on key insulin injection parameters, pain sensation scale and satisfaction of the treatment form before (visit 1) and after 3 months treatment with insulin injection (visit 2). The education was performed by trained healthcare professionals. To assess the utility and comfort during using new automatic injection system (GensuPen) we separated 2 groups: A – treated with GensuPen and B – treated with other pens. Results The education resulted in increased number of patients who properly remix cloudy insulin; inject insulin into skin; change every time the injection site; use the pen needle only once; prepare a pen for injection and store insulin. We noticed significant decrease in BMI and sensation of pain in both groups. Our study revealed that patients’ satisfaction with the treatment increased with each of the 5 items (type of the treatment, mood, physical activity, vital energy, a sense of control over the disease) using a 5-point scale, with greater increase in group A. The utility and comfort (weight, thickness, easiness in remove pen cap, cleaning, twisting, keeping in hand the pen, dial the dose, readable signaling of injected dose) during using the GensuPen significantly increased in group A. Finally the mean glucose level in self-control diary was significantly lower after 3 months of the treatment in both groups, however the difference between visit 1 and 2 was greater in group A. Conclusion The study showed that proper selection of pen and professional education can result in the improvement of insulin injection technique, higher patients’ satisfaction and better glycemic control.
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Fernandes J, Brijeetha V, Idiculla J. Prediction of lipohypertrophy in patients with diabetes mellitus. JOURNAL OF MAHATMA GANDHI INSTITUTE OF MEDICAL SCIENCES 2020. [DOI: 10.4103/jmgims.jmgims_58_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Thewjitcharoen Y, Prasartkaew H, Tongsumrit P, Wongjom S, Boonchoo C, Butadej S, Nakasatien S, Karndumri K, Veerasomboonsin V, Krittiyawong S, Himathongkam T. Prevalence, Risk Factors, and Clinical Characteristics of Lipodystrophy in Insulin-Treated Patients with Diabetes: An Old Problem in a New Era of Modern Insulin. Diabetes Metab Syndr Obes 2020; 13:4609-4620. [PMID: 33273836 PMCID: PMC7705266 DOI: 10.2147/dmso.s282926] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/21/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Lipodystrophy has been reported as a common complication in insulin-treated patients, which could lead to unexplained hypoglycemia and suboptimal glycemic control. This study aimed to determine the prevalence, associated risk factors, and clinical characteristics of insulin-induced lipodystrophy in Thai patients. PATIENTS AND METHODS This was a cross-sectional study involving insulin-treated patients at Theptarin Hospital, one of the largest diabetes centers in Thailand. RESULTS A total of 400 patients were studied (female 53.5%, T2DM 86%, mean age 65.6±15.4 years, duration of diabetes 23.0±10.2 years, median insulin treatment 10 years, usage of insulin analog 72.1%, A1C 7.9±1.6%) . The prevalence of lipohypertrophy (LH) in overall patients was 37.3% (T1DM 46.4% and T2DM 35.8%). The highest prevalence (57.5%) was observed in long-standing (≥10 years) T1DM patients. Multivariate analysis revealed that the duration of insulin use (≥10 years), use of human insulin, and incorrect rotation of injection sites were associated with LH. Patients with LH were found to have 7-times greater risk of unexplained hypoglycemia when compared with patients without LH. Lipoatrophy (LA) was found in only four cases (1.0%). All LA cases had a concurrence palpable area of LH. CONCLUSION Insulin-induced lipodystrophy is still an overlooked complication in the conundrum of diabetes care. The presence of lipodystrophy was significantly associated with the occurrence of unexplained hypoglycemia. It should be emphasized to recognize this condition by inspecting and palpating insulin injecting sites regularly, and educate patients to avoid the development of lipodystrophy.
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Affiliation(s)
- Yotsapon Thewjitcharoen
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
- Correspondence: Yotsapon Thewjitcharoen Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, ThailandTel +66-2-348-7000 Email
| | | | | | - Saruda Wongjom
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
| | | | - Siriwan Butadej
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
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Gentile S, Strollo F, Satta E, Della Corte T, Romano C, Guarino G. Insulin-Related Lipohypertrophy in Hemodialyzed Diabetic People: a Multicenter Observational Study and a Methodological Approach. Diabetes Ther 2019; 10:1423-1433. [PMID: 31222593 PMCID: PMC6612327 DOI: 10.1007/s13300-019-0650-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION End-stage renal disease (ESRD) is associated with increased cardiovascular mortality (CVM) and diabetes mellitus (DM), which in many cases is treated with insulin. Skin lipohypertrophy (LH) very often occurs in insulin-treated (IT) patients as a consequence of inadequate injection technique and is one of the most prominent contributors to hypoglycemia (HYPO), glycemic variability (GV), and poor metabolic control (PMC). METHOD The aim of our multicenter observational study was to assess LH prevalence at self-injection sites and any possible factors predicting high LH/HYPO rates and GV in 296 dialyzed ITDM patients characterized by 64 ± 7 years of age, 7 ± 2 years disease duration, 2.6 ± 2.2 years dialysis duration, preferred pen utilization (80%), and basal-bolus regimen (87.4%) with self-injections (62.6%) largely surpassing caregiver-assisted ones (16.9%), and a mix of the two injection methods (20.5%). RESULTS LH was detected in 57% of patients. Univariate analysis followed by backwards stepwise multivariate logistic regression function showed increased odds for developing LH in patients characterized by needle reuse, smaller injection areas, missed injection site rotation, higher HbA1c levels, and more prominent rates of HYPO and GV. CONCLUSION This was the first time such observation was made. It is now time for further studies aimed at providing evidence also in ESRD ITDM patients for the cause-effect relationship among wrong injection behavior, LH, and poor metabolic control and for the long-term preventative role of suitable educational countermeasures.
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Affiliation(s)
- Sandro Gentile
- Campania University "Luigi Vanvitelli", Naples, Italy.
- Nefrocenter Research Network, Naples, Italy.
| | - Felice Strollo
- Elle-Di and San Raffaele Research Institute, Rome, Italy
| | | | - Teresa Della Corte
- Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network, Naples, Italy
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Hirsch LJ, Strauss KW. The Injection Technique Factor: What You Don't Know or Teach Can Make a Difference. Clin Diabetes 2019; 37:227-233. [PMID: 31371853 PMCID: PMC6640874 DOI: 10.2337/cd18-0076] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IN BRIEF To be consistently effective, insulin must be delivered into subcutaneous tissue. If insulin is delivered intramuscularly, its uptake and action become variably faster, leading to suboptimal, inconsistent glucose control. The best strategy to avoid intramuscular injection is to use the shortest needles available. Injection sites should be rotated systematically to prevent lipohypertrophy, which also substantially affects insulin uptake and action. New evidence-based insulin delivery recommendations are available, and awareness of them should lead to more effective use of insulin therapy, improved clinical outcomes, and considerable cost savings.
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Pahuja V, Punjot P, Fernandes G, Chatterjee N. Exploring the factors associated with lipohypertrophy in insulin-treated type 2 diabetes patients in a tertiary care hospital in Mumbai, India. Int J Diabetes Dev Ctries 2019. [DOI: 10.1007/s13410-019-00735-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Deeb A, Abdelrahman L, Tomy M, Suliman S, Akle M, Smith M, Strauss K. Impact of Insulin Injection and Infusion Routines on Lipohypertrophy and Glycemic Control in Children and Adults with Diabetes. Diabetes Ther 2019; 10:259-267. [PMID: 30617932 PMCID: PMC6349294 DOI: 10.1007/s13300-018-0561-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Proper insulin injection/infusion is essential to optimize insulin absorption and action. Guidelines on insulin injection techniques are available. Lipohypertrophy (LH) is a local complication of insulin therapy, which results in erratic absorption and impaired glycemic control. METHODS Children and adults with type 1 diabetes on insulin injection or infusion were enrolled in the study. Subjects were interviewed and filled in a questionnaire on injection/infusion routines. Sites of injection/infusion were examined by trained diabetes educators, and capillary HbA1c was obtained. RESULTS One hundred sixty-nine subjects (104 children) with type 1 diabetes were enrolled; 119 were on multiple daily injection (MDI) and 50 on insulin pump therapy. Seventy-two percent and 82% of children and adults, respectively, rotate site at every injection; 78% of pump users change infusion set and 74% rotate site at 2-3 days. Thirty-nine percent and 32% of children and adults had LH. HbA1c was lower in children and adults with no LH (P < 0.001). An association was seen between LH and rotation frequency in children (P = 0.026). LH was the most common skin complication in the MDI group, while nodules, allergy marks and hyperpigmentation were seen in pump users. CONCLUSION Proper injection/infusion routines impact glycemic control and skin health. Education and examination of injection sites remain a crucial part of diabetes management.
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Affiliation(s)
- Asma Deeb
- Paediatric Endocrinology Department, Mafraq Hospital, P O Box 2951, Abu Dhabi, United Arab Emirates.
| | - Layla Abdelrahman
- Paediatric Endocrinology Department, Mafraq Hospital, P O Box 2951, Abu Dhabi, United Arab Emirates
| | - Mary Tomy
- Paediatric Endocrinology Department, Mafraq Hospital, P O Box 2951, Abu Dhabi, United Arab Emirates
| | - Shaker Suliman
- Paediatric Endocrinology Department, Mafraq Hospital, P O Box 2951, Abu Dhabi, United Arab Emirates
| | - Mariette Akle
- Paediatric Endocrinology Department, Mafraq Hospital, P O Box 2951, Abu Dhabi, United Arab Emirates
| | - Mike Smith
- BD Diabetes Care, Oxford Science Park, Oxford, OX4 4DQ, UK
| | - Ken Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium
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Jafarian-Amirkhizi A, Sarayani A, Gholami K, Taghizadeh-Ghehi M, Heidari K, Jafarzadeh-Kohneloo A, Morisky DE. Adherence to medications, self-care activity, and HbA1c status among patients with type 2 diabetes living in an urban area of Iran. J Diabetes Metab Disord 2018; 17:165-172. [PMID: 30918851 DOI: 10.1007/s40200-018-0356-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 09/09/2018] [Indexed: 11/30/2022]
Abstract
Background Appropriate pharmacotherapy, self-care and adherence to medications are crucial to diabetes control. We aimed to study the diabetes care and glycemic control in patients with type two diabetes living in an urban area of Iran. Methods In this cross-sectional study, patients with type 2 diabetes who attended a referral university affiliated community pharmacy and an accredited pathobiology laboratory in the 17th district of Tehran were evaluated. Data including demographics, medical and drug history were collected. Self-care activity (Diabetes Self-care Activity Measurement Scale) and medication adherence (8-item Morisky Medication Adherence scale) were also assessed. After completing the questionnaires, the patients were referred to the laboratory for Hemoglobin A1c test. Results Three hundred forty-eight patients (60.3% females) were recruited. The mean (SD) of patients' age was 55.82 (12.72) and 75.3%of them were Illiterate or had primary education. Mean (SD) of Hemoglobin A1c levels was 8.39 (2.03) and 33% of patients had levels higher than 9%. Among study patients, 186 (53.4%) patients received monotherapy for diabetes type 2 and 200 (57.5%) patients had low adherence to medications. Physical activity, blood glucose self-monitoring and foot care were domains of self-care with the fewest practice. Re-using a pen or syringe needle more than once was reported by 83% of patients and mean (SD) time of re-using a pen needle was 9.11 (8.74). Conclusion Poor glycemic control, low medication adherence, inadequate self-care activities, signals of inappropriate pharmacotherapy and inadequate medical visits and monitoring in the study patients highlight the importance of providing accessible and affordable health care services in the region. Moreover, educational needs of the patients should be considered especially in an area in which the majority of patients are old and illiterate and have low socioeconomic status.
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Affiliation(s)
| | - Amir Sarayani
- 2Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, 4th floor, No 92, Karimkhan Zand Ave., Hafte Tir Sq., Tehran, Iran
| | - Kheirollah Gholami
- 2Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, 4th floor, No 92, Karimkhan Zand Ave., Hafte Tir Sq., Tehran, Iran
| | - Maryam Taghizadeh-Ghehi
- 2Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, 4th floor, No 92, Karimkhan Zand Ave., Hafte Tir Sq., Tehran, Iran
| | - Kazem Heidari
- 3Department of Epidemiology and Biostatistics, Faculty of Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Aarefeh Jafarzadeh-Kohneloo
- 3Department of Epidemiology and Biostatistics, Faculty of Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Donald E Morisky
- 4Department of Community Health Sciences UCLA Fielding School of Public Health, Los Angeles, CA USA
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Tsadik AG, Atey TM, Nedi T, Fantahun B, Feyissa M. Effect of Insulin-Induced Lipodystrophy on Glycemic Control among Children and Adolescents with Diabetes in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. J Diabetes Res 2018; 2018:4910962. [PMID: 30116742 PMCID: PMC6079411 DOI: 10.1155/2018/4910962] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Lipodystrophy is one of the clinical complications of insulin injection that affects insulin absorption and leads to poor glycemic control. OBJECTIVE To assess insulin-induced lipodystrophy and glycemic control. METHODS A cross sectional study was done on 176 diabetic children and adolescents who inject insulin for a minimum of one year. First, anthropometric and clinical characteristics of the patients were recorded in questionnaire, and then observation and palpation techniques were used in assessing lipodystrophy. RESULT Out of the total 176 participants, 103 (58.5%) had insulin-induced lipodystrophy, of them 100 (97.1%) had lipohypertrophy and 3 (2.9%) had lipoatrophy. Being younger, failure to rotate the injection site every week and multiple reuse of insulin syringe had significant influence in development of insulin-induced lipohypertrophy. Lipohypertrophy in turn was associated with the use of higher dose of insulin and nonoptimal glycemic control. CONCLUSION Findings of this study revealed that in spite of using recombinant human insulin, the magnitude of the lipohypertrophy still remained high. Therefore, a routine workup of insulin-injecting patients for such complication is necessary, especially in the individuals who have a nonoptimal glycemic control.
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Affiliation(s)
- Afewerki Gebremeskel Tsadik
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Tesfay Mehari Atey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Teshome Nedi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bereket Fantahun
- Department of Pediatrics, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mamo Feyissa
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Gupta SS, Gupta KS, Gathe SS, Bamrah P, Gupta SS. Clinical Implications of Lipohypertrophy Among People with Type 1 Diabetes in India. Diabetes Technol Ther 2018; 20:483-491. [PMID: 29932731 DOI: 10.1089/dia.2018.0074] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) at insulin injection sites is a common but preventable complication in type 1 diabetes mellitus (T1DM). We evaluated the prevalence, contributing risk factors, and consequences of LH, specifically the glycemic variability (GV) among T1DM patients. METHODS This is a cross-sectional study conducted at a tertiary care center in India, wherein 139 subjects with T1DM were randomly selected and evaluated for the presence of LH through visual and palpation examinations. Demography, anthropometry, and injecting practices were evaluated using a validated questionnaire and their effect on LH was determined. Subsequently, the effect of LH on GV and unexplained hypoglycemia (UH) was studied. Mean glucose, mean amplitude of glycemic excursions (MAGEs), and continuous overlapping net glycemic action (CONGA) were assessed in a subset of patients who injected insulin alternately in LH and non-LH sites. RESULTS The overall prevalence of LH was 69.8%, and was significantly higher in adults than in children (P = 0.038). Improper rotation of sites (P < 0.0001) and insulin syringe reusage for more than five times (P = 0.009) significantly increase the risk of LH. The presence of LH has a significant effect on GV and UH with adjusted odds ratios of 17.65 (P < 0.0001) and 28.02 (P < 0.0001), respectively. Ambulatory glucose monitoring on a subset of patients confirmed that the mean glucose, MAGE, and CONGA were higher when subjects injected insulin at LH sites than at non-LH sites. CONCLUSIONS Improper rotation of sites and reuse of needles are the leading causes of LH in Indian T1DM patients, which, in turn, significantly increases the risk of GV and UH.
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Affiliation(s)
- Sunil S Gupta
- 1 Department of Diabetology, Sunil's Diabetes Care n' Research Centre , Nagpur, India
| | - Kavita S Gupta
- 2 Research Scholar, Rashtrasant Tukdoji Maharaj Nagpur University, MS, India and Department of Dietetics and Diabetes Education, Sunil's Diabetes Care n' Research Centre Pvt. Ltd. , Nagpur, India
| | - Sachin S Gathe
- 3 Department of Clinical Research and Epidemiology, Sunil's Diabetes Care n' Research Centre Pvt. Ltd. , Nagpur, India
| | | | - Shlok S Gupta
- 5 Student, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur; Maharashtra University of Health Sciences (Nashik), India
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Barola A, Tiwari P, Bhansali A, Grover S, Dayal D. Insulin-Related Lipohypertrophy: Lipogenic Action or Tissue Trauma? Front Endocrinol (Lausanne) 2018; 9:638. [PMID: 30425682 PMCID: PMC6218430 DOI: 10.3389/fendo.2018.00638] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 10/08/2018] [Indexed: 12/16/2022] Open
Abstract
Lipohypertrophy has been suggested as an outcome of lipogenic action of insulin and/or injection-related tissue trauma. In a cross-sectional study, we evaluated the predictors of lipohypertrophy in 372 type 1 diabetes patients (mean age 17.1 years) receiving subcutaneous insulin with pen and/or syringes for ≥3 months. On examining injection sites with inspection and palpation technique, 62.1% patients demonstrated lipohypertrophy. Univariate analysis showed that gender, BMI, HbA1c, injection device, rotation, injection area, needle length, insulin regimen, and total daily dose of insulin were associated with lipohypertrophy (p < 0.05). Notably, the mean needle reuse was comparable in patients with or without lipohypertrophy (8.1 vs. 7.2, p = 0.534). In multivariate logistic regression, gender, HbA1c, TDD, injection devices, and needle length lost its significance. Further, injections over smaller area (≤8.5 × 5.5 cm) and non-rotation of sites were found to be strongest independent predictor of lipohypertrophy (p < 0.0005 for both) with increased odds of 23.2 (95% CI 9.1-59.2) and 6.3 (95% CI 3.4-11.9) times, respectively. Being underweight was also a significant independent predictor (odds ratio [OR] 13.0 [95% CI 2.2-75.2], p = 0.004). Compared to rapid plus long-acting analogs, regular insulin plus long-acting analogs and conventional premixed insulin users had 3.2 (95% CI 1.5-6.8, p = 0.003) and 4.6 (95% CI 1.4-15.7, p = 0.014) fold higher risk of lipohypertrophy (mean injection frequency 4.01 vs. 4.01 vs. 2.09, respectively). Sub-group analysis showed that lipohypertrophy was 79% less likely in patients with multiple daily injections (≥4) than twice-daily regimen (OR 0.21, p < 0.0005). Moreover, lipohypertrophy was reduced to half with bolus doses of rapid-acting insulin analogs than regular insulin (p = 0.003), even though mean injection frequency was comparable (4.01 vs. 3.93, p = 0.229). This difference was statistically insignificant for basal doses with NPH or long-acting analogs (p = 0.069). Therefore, injection area, rotation, BMI, and insulin regimen are the best predictors of lipohypertrophy and together could correctly identify lipohypertrophy status in 84.4% patients with excellent discrimination capability (AUC = 0.906, p < 0.0005). In conclusion, findings of our study suggest that delivering rapidly absorbed insulin analogs over large injection area along with greater split of total daily doses reduce insulin-induced lipogenesis and outplay tissue trauma added through frequent injections and needle reuse.
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Affiliation(s)
- Anjana Barola
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Pramil Tiwari
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- *Correspondence: Anil Bhansali
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devi Dayal
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Pozzuoli GM, Laudato M, Barone M, Crisci F, Pozzuoli B. Errors in insulin treatment management and risk of lipohypertrophy. Acta Diabetol 2018; 55:67-73. [PMID: 29098390 DOI: 10.1007/s00592-017-1066-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/21/2017] [Indexed: 02/05/2023]
Abstract
AIMS Lipohypertrophy (LH) represents the most common skin-related complication associated with insulin therapy. Our aim is to estimate the prevalence of LH among insulin-treated patients, to identify its association with errors in insulin injection technique and storage, and the correlation between LH, risk of hypoglycemia, and glycemic control. METHODS Consecutive patients with T1DM or T2DM, attending a diabetes clinic for a routine visit, were administered an anonymous questionnaire investigating the modalities of insulin injection, the correct use of pen device, insulin storage, and reported frequency of hypoglycemic episodes. The presence of LH was assessed by inspection and palpation of injection sites. RESULTS Overall, 352 patients were enrolled (mean age 68 ± 12 years, 43.2% males, 88.9% with T2DM, mean duration of insulin therapy 9.1 ± 8.6 years). The prevalence of LH was 42.9%. At multivariate analysis, the strongest correlates of LH were not spacing injections (OR 20.4; 95% CI 10.5-39.6) and not rotating the site of injection (OR 2.01; 95% CI 1.08-3.75). Increasing doses of insulin and longer duration of insulin therapy also increased the risk of LH. The presence of LH was associated with a 2.7 times higher risk of severe hypoglycemia. Higher daily insulin doses, lack of rotation of injection sites, and keeping insulin in use in the refrigerator were independent correlates of higher HbA1c levels. CONCLUSIONS Insulin injection technique is suboptimal in many patients, highlighting the need for improved patient education. Increasing the awareness of the importance of preventing lipohypertrophy and insulin injection errors represents an important tool to reduce the clinical, social, and economic burden of diabetes.
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Affiliation(s)
| | - Mario Laudato
- Azienda Sanitaria Locale Caserta, Centro Diabetologico, via Harris, 81100, Caserta, Italy
| | - Maria Barone
- Azienda Sanitaria Locale Caserta, Centro Diabetologico, via Harris, 81100, Caserta, Italy
| | - Franco Crisci
- Università degli Studi Della Campania: L. Vanvitelli. Corso di Laurea in Infermieristica. ASL CE, via Napoli, 81024, Maddaloni, Italy
| | - Bianca Pozzuoli
- Università degli Studi Della Campania: L. Vanvitelli. Corso di Laurea in Infermieristica. ASL CE, via Napoli, 81024, Maddaloni, Italy
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Campinos C, Le Floch JP, Petit C, Penfornis A, Winiszewski P, Bordier L, Lepage M, Fermon C, Louis J, Almain C, Morel D, Hirsch L, Strauss KW. An Effective Intervention for Diabetic Lipohypertrophy: Results of a Randomized, Controlled, Prospective Multicenter Study in France. Diabetes Technol Ther 2017; 19:623-632. [PMID: 29058477 PMCID: PMC5750448 DOI: 10.1089/dia.2017.0165] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) is highly prevalent and is potentially harmful to insulin-injecting patients. METHODS In this study, we assessed the impact of injection technique (IT) education, including use of a 4-mm pen needle on insulin-treated patients with clinically observed LH in a randomized, controlled, prospective multicenter study in France with follow-up of 6 months. Intensive education and between-visit reinforcement were given to the intervention group. Control patients received similar messages at study outset. RESULTS A total of 123 patients were recruited (age 52.1 ± 15.7 years; men 70.7%; body mass index >30 kg/m2: 34.2%; type 1: 53.7%; years with diabetes mellitus: 18.1 ± 10.5), of which 109 patients were included in the final analysis. The intervention group (n = 53) showed a significant decrease of total daily dose of insulin (average at baseline: 54.1 IU) at 3 months (T-3) and 6 months (T-6), reaching just over 5 IU versus baseline (P = 0.035). Corresponding, although not significant, decreases occurred in controls (n = 56); between-group differences were not significant. There were significant decreases in HbA1c (up to 0.5%) at T-3 and T-6 in both groups, with no significant differences between groups. A significant number of intervention patients improved their IT habits; about half achieved ideal IT habits by T-3 versus a quarter of control patients. By T-6, 2/3 of intervention patients achieved either ideal or acceptable IT habits, while only 1/3 of control patients did. CONCLUSIONS Our intervention was effective in both study arms, however, to a greater degree and more rapidly in the intervention group. Widespread application of this intervention could be highly cost-effective.
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Affiliation(s)
| | | | - Catherine Petit
- CH Sud Francilien Diabetes Service, Corbeil-Essonnes, France
| | - Alfred Penfornis
- Université Paris Sud Diabetes Service, CH Sud Francilien, Corbeil-Essonnes, France
| | | | - Lyse Bordier
- H.I.A. Begin Diabetes Service, Saint Mande, France
| | - Marie Lepage
- C.H.B. Diabetes Service, Boulogne sur Mer Cedex, France
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Patil M, Sahoo J, Kamalanathan S, Selviambigapathy J, Balachandran K, Kumar R, Vivekanandan M, Ajmal K. Assessment of insulin injection techniques among diabetes patients in a tertiary care centre. Diabetes Metab Syndr 2017; 11 Suppl 1:S53-S56. [PMID: 27614866 DOI: 10.1016/j.dsx.2016.09.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 09/03/2016] [Indexed: 12/17/2022]
Abstract
AIMS The efficacy of insulin therapy in diabetes depends on proper storage and injection technique. The purpose of this study was to assess the practice of insulin administration among diabetes patients in a tertiary care center. MATERIALS AND METHODS This observational study was done in Endocrinology department of a tertiary care center during April-June 2015. The consecutive patients using insulin for at least three months by either syringe or pen were recruited. All of them underwent a survey by the questionnaire which focused on key insulin injection parameters. RESULTS One hundred and sixty eight (74.67%) patients were storing insulin vials properly. The thigh was the most common site of insulin injection and 209(92.89%) study participants were rotating at the injection sites. Only 48.57% (34/70) subjects were mixing insulin properly before injection. The practice of hand washing and the cleaning of the injection site was practiced by 158(70%) & 171(76.44%) subjects respectively. One hundred and fifty six (69%) patients were injecting with the proper skin fold and 123(55%) subjects were injecting insulin at 90° angle. The majority of patients (91%) were throwing the needle and syringes directly into the garbage and public drainage system. CONCLUSIONS There was a significant gap between the insulin administration guidelines and current insulin injection practice. The diabetic education and counseling about proper insulin injection techniques should be provided to all diabetic subjects.
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Affiliation(s)
- Milind Patil
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Jayaprakash Sahoo
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India.
| | - Sadishkumar Kamalanathan
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Jayakumar Selviambigapathy
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Karthik Balachandran
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Ritesh Kumar
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Muthupillai Vivekanandan
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - K Ajmal
- Department of Endocrinology & Metabolism, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Deng N, Zhang X, Zhao F, Wang Y, He H. Prevalence of lipohypertrophy in insulin-treated diabetes patients: A systematic review and meta-analysis. J Diabetes Investig 2017; 9:536-543. [PMID: 28862814 PMCID: PMC5934253 DOI: 10.1111/jdi.12742] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 08/06/2017] [Accepted: 08/21/2017] [Indexed: 01/10/2023] Open
Abstract
AIMS/INTRODUCTION Insulin-treated diabetes patients are at high risk for lipohypertrophy (LH), but this clinical problem has been overlooked by some medical professionals. In addition, studies differed from each other significantly in regard to the prevalence of LH. The present systematic review aimed to determine pooled prevalence levels of LH among insulin-injecting diabetes patients. MATERIALS AND METHODS Four electronic databases (PubMed, EMBASE, The Cochrane Library and Scopus) were searched for eligible studies from their inception until April 2017, and reference lists were searched manually to identify additional studies. Studies containing data on LH in patients with diabetes mellitus were included. Meta-analysis was carried out with a random effects model. RESULTS A total of 26 studies with a total of 12,493 participants met the inclusion criteria. Meta-analysis showed that the pooled prevalence of LH was 38% (95% confidence interval [CI] 29-46%, I2 = 99.1%). The main influence on LH was the type of diabetes mellitus. The pooled prevalence of LH among patients with type 2 diabetes mellitus was higher than patients with type 1 diabetes mellitus (49%, 95% CI 23-74% vs 34%, 95% CI 19-49%). The pooled prevalence of LH of studies involving a mixed type of diabetes mellitus was 37% (95% CI 25-48%, I2 = 98.3%). CONCLUSION The prevalence of LH was high in insulin-treated diabetes patients. It showed that diabetes nurses should screen for LH regularly in their patients, and teach them how to prevent LH in their daily management of diabetes mellitus.
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Affiliation(s)
- Nan Deng
- Department of NursingAffiliated Hospital of Nantong UniversityNantongChina
- Nursing School of Nantong UniversityNantongChina
| | - Xiaoyi Zhang
- Department of EndocrinologyAffiliated Hospital of Nantong UniversityNantongChina
| | | | - Ya Wang
- Nursing School of Nantong UniversityNantongChina
| | - Hong He
- Department of NursingAffiliated Hospital of Nantong UniversityNantongChina
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Theofanidis D. In-Hospital Administration of Insulin by Nurses in Northern Greece: An Observational Study. Diabetes Spectr 2017; 30:175-181. [PMID: 28848311 PMCID: PMC5556589 DOI: 10.2337/ds16-0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study is to explore current practice regarding insulin administration by nurses in a Greek public hospital. DESIGN AND METHODS A mixed-methods qualitative data collection design was used with ad hoc nonparticipant observation and post hoc interviews with the staff involved. Insulin management and administration was observed and compared to international guidelines. A sample of 20 nurses from two medical wards was assessed on 100 occasions of insulin administration, and 8 nurses were subsequently interviewed. RESULTS Inter-rater agreement was found to be satisfactory (average κ 0.840). In 61% of all instances, nurses washed their hands before administering insulin, and, in 70%, they donned gloves before injections. In 64.5% of all instances, the nurses did not clean the insulin bottle before inserting the needle, and in 42.7% of instances, they did not check for air bubbles in the syringe. In 89.1% of instances, nurses did not check the injection site for appropriateness or other possible complications. However, in 90.9%, they cleaned the skin at the injection site with an alcohol swab. In 70.9% of all instances, the needle was placed vertically to the skin but without a skinfold. In 89.1% of instances, post-injection care was rated as poor. CONCLUSION Overall, compliance with international guidelines regarding insulin administration techniques, as observed in these sample wards, is not satisfactory. Nurses in this Greek hospital tend to administer subcutaneous injections in ways not reflected in current research findings, practice guidelines, or evidence-based care recommendations. Evidently, Greek nurses in this sample require updating on current evidence-based practice, clinical guidelines, and protocols of care regarding routine insulin administration.
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Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B, Ghosh S, Sanyal D, Hirsch LJ, Gupta V, Strauss KW. Indian Injection Technique Study: Injecting Complications, Education, and the Health Care Professional. Diabetes Ther 2017; 8:659-672. [PMID: 28289892 PMCID: PMC5446373 DOI: 10.1007/s13300-017-0244-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Using the Indian and rest of world (ROW) injection technique questionnaire (ITQ) data, we address key insulin injection complications. METHODS In 2015 we conducted an ITQ survey throughout India involving 1011 patients. Indian values were compared with those from 41 other countries participating in the ITQ, known here as ROW. RESULTS More than a quarter of Indian insulin users described lesions consistent with lipohypertrophy (LH) at their injection sites and approximately 1 in 5 were found to have LH by the examining nurse (using visual inspection and palpation). Just over half of Indian injectors report having pain on injection. Of these, 4 out of 5 report having painful injections only several times a month or year (i.e., not with every injection). Doctors and diabetes educators in India (as opposed to nurses) have a larger role in teaching patients how to inject than they do in ROW. Despite this specialized approach, a very high percentage of patients report that they have not been trained (at least cannot remember being trained) in a wide range of essential injection topics. Only about 30% of Indian injectors get their sites checked at least annually, with nearly a third only having sites checked when they specifically complained and nearly 4 out of 10 never having had their sites checked. CONCLUSION Indian HCPs can clearly do a better job covering all the vital topics essential to proper injection habits.
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Affiliation(s)
| | - Ambrish Mithal
- Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, India
| | - Rakesh Sahay
- Osmania Medical College, Turrebaz Khan Rd, Esamiya Bazaar, Koti, Hyderabad, Telangana, India
| | - Mathew John
- Providence Endocrine and Diabetes Specialty Centre, TC 1/2138, Near GG Hospital, Murinjapalam, Thiruvananthapuram, Kerala, India
| | - A G Unnikrishnan
- Chellaram Diabetes Institute, Pune-Bangalore, NH4, Bavdhan, Pune, Maharashtra, India
| | - Banshi Saboo
- Diacare-Diabetes Care and Hormone Clinic, 1 and 2 Gandhi Park Society, Nehrunagar Cross Roads, Ambavadi, Ahmedabad, Gujarat, India
| | - Sujoy Ghosh
- AMRI Medical Centre Kolkata, No. 97 A, Southern Avenue, Above Maruti Showroom, Opposite Lake Stadium, Kolkata, West Bengal, India
| | - Debmalya Sanyal
- KPC Medical College and Hospital, Kolkata, F, Raja Subodh Chandra Mullick Road, Jadavpur, Near Jadavpur Railway Station, Kolkata, West Bengal, India
| | | | - Vandita Gupta
- BD Diabetes Care, BD, 6th Floor Signature Tower-B, South City I, NH 8, Gurgaon, Haryana, India
| | - Kenneth W Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium.
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Smith M, Clapham L, Strauss K. UK lipohypertrophy interventional study. Diabetes Res Clin Pract 2017; 126:248-253. [PMID: 28288434 DOI: 10.1016/j.diabres.2017.01.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/18/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Lipohypertrophy (LH) is one of the most common complications of insulin therapy. We conducted a prospective study in 18 UK centres to assess the impact of a targeted LH intervention on a range of clinical, biological and socio-economic parameters. METHODS Seventy-five insulin-injecting patients were recruited randomly and were followed prospectively for 3-6months, with results compared to baseline values. Interventions included the use of an intensive education program and a switch to a 4mm pen needle. RESULTS At all injection sites LH decreased significantly by the end of the study, either disappearing completely or shrinking by approximately 50% from its original diameter. Injections into LH decreased by more than 75% by the end. Most patients were not correctly rotating injection sites at the beginning but by the end most were, by a 5-fold margin. Only 1/3 of our subjects used the 4mm needle at the beginning of the study, however, virtually all did by study end. The mean HbA1c improved by more than 4mmol/L and there were significantly lower levels of unexpected hypoglycaemia and glucose variability. Total daily doses of insulin dropped by an average of 5.6 IU by study end. CONCLUSIONS We believe the impressive clinical improvements seen with training to prevent LH can be achieved by wide adoption of the interventions outlined in this study.
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Affiliation(s)
- Mike Smith
- BD Diabetes Care, The Danby Building, Edmund Halley Road, Oxford Science Park, Oxford OX4 4DQ, UK.
| | - Linda Clapham
- Wharfedale Diabetes Centre, Wharfedale Hospital, Newall Carr Road, Otley, Leeds Teaching Hospitals, LS21 2LY Leeds, UK.
| | - Kenneth Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, B-9320 Erembodegem, Belgium.
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Frid AH, Kreugel G, Grassi G, Halimi S, Hicks D, Hirsch LJ, Smith MJ, Wellhoener R, Bode BW, Hirsch IB, Kalra S, Ji L, Strauss KW. New Insulin Delivery Recommendations. Mayo Clin Proc 2016; 91:1231-55. [PMID: 27594187 DOI: 10.1016/j.mayocp.2016.06.010] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 12/14/2022]
Abstract
Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.
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Affiliation(s)
- Anders H Frid
- Department of Endocrinology, Skane University Hospital, Malmö, Sweden
| | - Gillian Kreugel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Giorgio Grassi
- Città della Salute e della Scienza Torino, Torino, Italy
| | - Serge Halimi
- University for Sciences and Medicine Joseph Fourier Grenoble and Diabetology Department CHU Grenoble, Grenoble Cedex, France
| | - Debbie Hicks
- Barnet, Enfield & Haringey Mental Health Trust, London, UK
| | | | | | | | | | - Irl B Hirsch
- University of Washington Medical Center-Roosevelt, Seattle
| | | | - Linong Ji
- Peking University Peoples Hospital, Beijing, China
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Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide Injection Technique Questionnaire Study: Population Parameters and Injection Practices. Mayo Clin Proc 2016; 91:1212-23. [PMID: 27594185 DOI: 10.1016/j.mayocp.2016.06.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 12/17/2022]
Abstract
From February 1, 2014, through June 30, 2015, 13,289 insulin-injecting patients from 423 centers in 42 countries took part in one of the largest surveys ever performed in diabetes. The goal was to assess patient characteristics, as well as historical and practical aspects of their injection technique. Results show that 4- and 8-mm needle lengths are each used by nearly 30% of patients and 5- and 6-mm needles each by approximately 20%. Higher consumption of insulin (as measured by total daily dose) is associated with having lipohypertrophy (LH), injecting into LH, leakage from the injection site, and failing to reconstitute cloudy insulin. Glycated hemoglobin values are, on average, 0.5% higher in patients with LH and are significantly higher with incorrect rotation of sites and with needle reuse. Glycated hemoglobin values are lower in patients who distribute their injections over larger injection areas and whose sites are inspected routinely. The frequencies of unexpected hypoglycemia and glucose variability are significantly higher in those with LH, those injecting into LH, those who incorrectly rotate sites, and those who reuse needles. Needles associated with diabetes treatment are the most commonly used medical sharps in the world. However, correct disposal of sharps after use is critically suboptimal. Many used sharps end up in public trash and constitute a major accidental needlestick risk. Use of these data should stimulate renewed interest in and commitment to optimizing injection practices in patients with diabetes.
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Affiliation(s)
- Anders H Frid
- Department of Endocrinology, Skane University Hospital, Malmö, Sweden
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Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide Injection Technique Questionnaire Study: Injecting Complications and the Role of the Professional. Mayo Clin Proc 2016; 91:1224-30. [PMID: 27594186 DOI: 10.1016/j.mayocp.2016.06.012] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Abstract
From February 1, 2014, through June 30, 2015, 13,289 insulin-injecting patients from 423 centers in 42 countries participated in one of the largest surveys ever performed in diabetes. The first results of this survey are published elsewhere in this issue. Herein we report that the most common complication of injecting insulin is lipohypertrophy (LH), which was self-reported by 29.0% of patients and found by physical examination in 30.8% by health care professionals (HCPs). Patients with LH consumed a mean of 10.1 IU more insulin daily than patients without LH. Glycated hemoglobin levels averaged 0.55% higher in patients with vs without LH. Lipohypertrophy was associated with higher rates of unexplained hypoglycemia and glycemic variability as well as more frequent diabetic ketoacidosis, incorrect rotation of injection sites, use of smaller injection zones, longer duration of insulin use, and reuse of pen needles (each P<.05). Routine inspection of injection sites by the HCP was associated with lower glycated hemoglobin levels, less LH, and more correct injection site rotation. Patients were also more likely to rotate correctly if they received injection instructions from their HCP in the past 6 months. Fewer than 40% of patients claimed to have gotten such instructions in the past 6 months, and 10% said that they have never received training on how to inject correctly despite injecting for a mean of nearly 9 years. Use of these data should stimulate renewed commitment to optimizing insulin injection practices.
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Affiliation(s)
- Anders H Frid
- Department of Endocrinology, Skane University Hospital, Malmö, Sweden
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Gentile S, Strollo F, Ceriello A. Lipodystrophy in Insulin-Treated Subjects and Other Injection-Site Skin Reactions: Are We Sure Everything is Clear? Diabetes Ther 2016; 7:401-9. [PMID: 27456528 PMCID: PMC5014793 DOI: 10.1007/s13300-016-0187-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Indexed: 01/06/2023] Open
Abstract
Physicians and patients have long been aware of skin lesions at the sites of insulin injections, referred to as lipodystrophy that can present as lipoatrophy (LA) or lipohypertrophy (LH). However, the reported prevalence of these different skin lesions varies widely, emphasizing the need for a correct identification method. In this short review we discuss LA and LH and also take into account other skin lesions, such as bruising, as well as different needle injuries, including those associated with the subcutaneous injection of pegvisomant (a drug aimed at counteracting the high levels of growth hormone associated with acromegaly), long-acting exenatide (a glucagon-like peptide-1 receptor agonist), and anti-tumor necrosis factor-alpha biologic agents (used against Crohn's disease). In these latter cases specific studies are warranted to understand the pathophysiological background and possible prevention. However, the most common lesion is still insulin injection site-related LD, so a strong effort has to be made to avoid the confusion generated by previously misleading classifications which were barely able to reliably distinguish between LA and LH.
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Affiliation(s)
- Sandro Gentile
- Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Felice Strollo
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.
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Abstract
The formation of insulin amyloid can dramatically impact glycemic control in patients with diabetes, making it an important therapeutic consideration. In addition, the cost associated with the excess insulin required by patients with amyloid is estimated to be $3K per patient per year, which adds to the growing financial burden of this disease. Insulin amyloid has been observed with every mode of therapeutic insulin administration (infusion, injection and inhalation), and the number of reported cases has increased significantly since 2002. The new cases represent a much broader demographic, and include many patients who have used exclusively human insulin and human insulin analogs. The reason for the increase in case reports is unknown, but this review explores the possibility that changes in patient care, improved differential diagnosis and/or changes in insulin type and insulin delivery systems may be important factors. The goal of this review is to raise key questions that will inspire proactive measures to prevent, identify and treat insulin amyloid. Furthermore, this comprehensive examination of insulin amyloid can provide insight into important considerations for other injectable drugs that are prone to form amyloid deposits.
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Affiliation(s)
- Melanie R Nilsson
- a Department of Chemistry , McDaniel College , Westminster , MD , USA
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Spollett G, Edelman SV, Mehner P, Walter C, Penfornis A. Improvement of Insulin Injection Technique: Examination of Current Issues and Recommendations. DIABETES EDUCATOR 2016; 42:379-94. [PMID: 27216036 DOI: 10.1177/0145721716648017] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE Correct insulin injection technique is a crucial aspect of diabetes management. The purpose of this article is (1) to outline the medical literature, including patient-based studies and surveys, surrounding the type of issues and problems that patients encounter with injectable insulin therapy and the degree to which correct insulin technique is being applied and (2) to review the latest recommendations for insulin injection technique and discuss the key aspects that diabetes educators and other health care professionals should be communicating to their patients to ensure that injection technique is optimized. CONCLUSIONS Examination of the literature and multiple patient surveys demonstrates that patients continue to have many issues with insulin injection technique, highlighting the pressing need for effective patient education. In addition, many patients are not using insulin pen devices correctly. Widespread lack of injection site rotation and reuse of needles have resulted in high rates of lipohypertrophy. Lipohypertrophy has in turn been associated with significantly increased levels of unexplained hypoglycemia and glycemic variability and significantly increased insulin costs. By providing clear, evidence-based consensus recommendations, initiatives such as the Forum for Injection Technique are helping to address these issues but will be successful only if concerted efforts in patient education and reeducation are made to ensure that these recommendations are implemented consistently. This should involve all stakeholders in insulin therapy-particularly diabetes educators, who are at the forefront of patient education.
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Affiliation(s)
- Geralyn Spollett
- Department of Internal Medicine, Yale Diabetes Center, Yale School of Medicine, New Haven, Connecticut (Ms Spollett)
| | - Steven V Edelman
- Department of Medicine, Division of Endocrinology, University of California-San Diego, San Diego, California (Dr Edelman)
| | | | - Claudia Walter
- Special Doctor's Office in Endocrinology and Diabetes, Gunzenhausen, Germany (Ms Walter)
| | - Alfred Penfornis
- Department of Diabetology and Endocrinology, Sud-Francilien Hospital, Corbeil-Essonnes, Paris-Sud University, France (Dr Penfornis)
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Zabaleta-Del-Olmo E, Vlacho B, Jodar-Fernández L, Urpí-Fernández AM, Lumillo-Gutiérrez I, Agudo-Ugena J, Morros-Pedrós R, Violán C. Safety of the reuse of needles for subcutaneous insulin injection: A systematic review and meta-analysis. Int J Nurs Stud 2016; 60:121-32. [PMID: 27297374 DOI: 10.1016/j.ijnurstu.2016.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/30/2016] [Accepted: 04/20/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Many people with diabetes often reuse disposable needles for subcutaneous insulin injection. We aimed to identify, critically appraise and summarize the available evidence about the safety of this practice. DESIGN Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES MEDLINE (via PubMed), CINALH (via EBSCO), SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials and Open Grey were searched from their inception to December 2015, with no language restrictions. REVIEW METHODS Epidemiologic and experimental studies assessing adverse effects of reusing needles in people of any age or sex, with or without diabetes, were included. Two reviewers independently assessed the methodological quality of included studies using a multi-design tool. RESULTS In total, 25 studies were included. All studies had a high risk of bias and data from only nine studies could be pooled. Five studies showed no association between infection at site of injection and reuse of needles (risk difference=-0.00; 95% confidence interval=-0.12-0.11; P=0.99); heterogeneity between these studies was substantial (I(2)=66%; P=0.02). Five cross-sectional studies showed an association between lipohypertrophy and needle reuse (risk difference=0.16, 95% confidence interval=0.05-0.28, P=0.006); there was strong evidence of heterogeneity between these studies (I(2)=87%; P<0.001). Pooled data of two studies with no evidence of heterogeneity between them showed more perceived pain among reusers (risk difference=0.24; 95% confidence interval=0.06-0.43; P=0.006). Reusing a pen needle or disposable syringe-needle was not associated with worse glycaemic control. CONCLUSIONS There is currently no clear scientific evidence to suggest for or against the reuse of needles for subcutaneous insulin injection. This practice is very common among people with diabetes; consequently, further research is necessary to establish its safety.
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Affiliation(s)
- Edurne Zabaleta-Del-Olmo
- Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Gran Via Corts Catalanes, 587 àtic, 08007 Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain; Department of Nursing, Universitat de Girona, c/ Emili Grahit 77, 17071 Girona, Spain.
| | - Bogdan Vlacho
- Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Gran Via Corts Catalanes, 587 àtic, 08007 Barcelona, Spain.
| | - Lina Jodar-Fernández
- Primary Health Care Centre Cornellà 2 (Sant Ildefons), Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Av. República Argentina s/n (cantonada Av. de Sant Ildefons), 08940 Cornellà de Llobregat, Spain.
| | - Ana-María Urpí-Fernández
- Primary Health Care Centre Carles I, Àmbit d'Atenció Primària Barcelona-Ciutat, Institut Català de la Salut, c. de la Marina, 168, 08018 Barcelona, Spain.
| | - Iris Lumillo-Gutiérrez
- Emergency Primary Care Centre El Castell, Consorci Castelldefels Agents de Salut (CASAP), c. Guillermo Marconi, 9 bxs, 08860 Castelldefels, Spain.
| | - Josep Agudo-Ugena
- Primary Health Care Centre La Mina, Àmbit d'Atenció Primària Barcelona-Ciutat, Institut Català de la Salut, c. del Mar, s/n, 08930 Sant Adrià de Besòs, Spain.
| | - Rosa Morros-Pedrós
- Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Gran Via Corts Catalanes, 587 àtic, 08007 Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain.
| | - Concepción Violán
- Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Gran Via Corts Catalanes, 587 àtic, 08007 Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain.
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Berard L, Cameron B. Injection Technique Practices in a Population of Canadians with Diabetes: Results from a Recent Patient/Diabetes Educator Survey. Can J Diabetes 2015; 39:146-51. [DOI: 10.1016/j.jcjd.2014.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/07/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
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Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size for subcutaneous insulin administration on metabolic control and patient acceptance. ACTA ACUST UNITED AC 2015. [DOI: 10.1002/edn.77] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Teska BM, Kumar A, Carpenter JF, Wempe MF. Analyzing insulin samples by size-exclusion chromatography: a column degradation study. J Pharm Sci 2015; 104:1555-60. [PMID: 25581527 DOI: 10.1002/jps.24330] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/27/2014] [Accepted: 12/04/2014] [Indexed: 11/09/2022]
Abstract
Investigating insulin analogs and probing their intrinsic stability at physiological temperature, we observed significant degradation in the size-exclusion chromatography (SEC) signal over a moderate number of insulin sample injections, which generated concerns about the quality of the separations. Therefore, our research goal was to identify the cause(s) for the observed signal degradation and attempt to mitigate the degradation in order to extend SEC column lifespan. In these studies, we used multiangle light scattering, nuclear magnetic resonance, and gas chromatography-mass spectrometry methods to evaluate column degradation. The results from these studies illustrate: (1) that zinc ions introduced by the insulin product produced the observed column performance issues; and (2) that including ethylenediaminetetraacetic acid, a zinc chelator, in the mobile phase helped to maintain column performance.
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Affiliation(s)
- Brandon M Teska
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, 80045
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Thomsen M, Hernandez-Garcia A, Mathiesen J, Poulsen M, Sørensen DN, Tarnow L, Feidenhans'l R. Model study of the pressure build-up during subcutaneous injection. PLoS One 2014; 9:e104054. [PMID: 25122138 PMCID: PMC4133188 DOI: 10.1371/journal.pone.0104054] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/04/2014] [Indexed: 11/21/2022] Open
Abstract
In this study we estimate the subcutaneous tissue counter pressure during drug infusion from a series of injections of insulin in type 2 diabetic patients using a non-invasive method. We construct a model for the pressure evolution in subcutaneous tissue based on mass continuity and the flow laws of a porous medium. For equivalent injection forces we measure the change in the infusion rate between injections in air at atmospheric pressure and in tissue. From a best fit with our model, we then determine the flow permeability as well as the bulk modulus of the tissue, estimated to be of the order 10-11-10-10 m2 and 105 Pa, respectively. The permeability is in good agreement with reported values for adipose porcine tissue. We suggest our model as a general way to estimate the pressure build-up in tissue during subcutaneous injection.
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Affiliation(s)
- Maria Thomsen
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk A/S, Hillerød, Denmark
| | | | | | | | | | - Lise Tarnow
- Nordsjæ llands Hospital, Hillerød, Denmark
- Klinisk Epidemiologisk Afdeling, Aarhus Universitetshospital, Aarhus, Denmark
- Steno Diabetes Center A/S, Gentofte, Denmark
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Teska BM, Alarcón J, Pettis RJ, Randolph TW, Carpenter JF. Effects of phenol and meta-cresol depletion on insulin analog stability at physiological temperature. J Pharm Sci 2014; 103:2255-67. [PMID: 24909933 DOI: 10.1002/jps.24039] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 05/13/2014] [Accepted: 05/16/2014] [Indexed: 11/11/2022]
Abstract
The stability of three commercial "fast-acting" insulin analogs, insulin lispro, insulin aspart, and insulin glulisine, was studied at various concentrations of phenolic preservatives (phenol and/or meta-cresol) during 9 days of incubation at 37 °C. The analysis by both size-exclusion and reversed-phase chromatography showed degradation of lispro and aspart that was inversely dependent on the concentration of phenolic preservatives. Insulin glulisine was much more stable than the other analogs and showed minimal degradation even in the absence of phenolic preservatives. With sedimentation velocity ultracentrifugation, we determined the preservatives' effect on the insulins' self-assembly. When depleted of preservatives, insulin glulisine dissociates from higher molecular weight species into a number of intermediate molecular weight species, in between monomer and hexamer, whereas insulin aspart and insulin lispro dissociate into monomers and dimers. Decreased stability of insulin lispro and insulin aspart seems to be because of the extent of dissociation when depleted of preservative. Insulin glulisine's dissociation to intermediate molecular weight species appears to help minimize its degradation during incubation at 37 °C.
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Affiliation(s)
- Brandon M Teska
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, 80045
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48
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Arcebido R, Wong E, Cohen V, Likourezos A. Pharmacist-led discharge counseling on subcutaneous insulin use and administration. Am J Health Syst Pharm 2014; 70:1371-3. [PMID: 23903474 DOI: 10.2146/ajhp120571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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49
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Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. DIABETES & METABOLISM 2013; 39:445-53. [DOI: 10.1016/j.diabet.2013.05.006] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/05/2013] [Accepted: 05/12/2013] [Indexed: 11/24/2022]
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50
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Hirsch L, Gibney M, Berube J, Manocchio J. Impact of a modified needle tip geometry on penetration force as well as acceptability, preference, and perceived pain in subjects with diabetes. J Diabetes Sci Technol 2012; 6:328-35. [PMID: 22538142 PMCID: PMC3380774 DOI: 10.1177/193229681200600216] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple factors impact subcutaneous insulin injection pain. Injection devices [e.g., syringe or pen needle (PN)] affect pain due to needle length, diameter, needle polishing and lubrication, and needle tip geometry. METHODS We evaluated a modified 5-bevel PN tip in 32 G × 4 mm 31 G × 5 mm and 8 mm PNs vs the equivalent marketed 3-bevel PNs in laboratory penetration force testing, as well as in insulin-taking subjects for overall acceptability, comparative pain, and preference. The clinical tests were done in three ways: paired insertions with the subjects blinded to PN tip geometry, after brief at-home use of 5-bevel PNs, and again with subjects informed about each needle's tip geometry in paired insertions. RESULTS Average penetration force in a skin substitute was 23% lower with the 5-bevel PNs vs similar 3-bevel PNs (p ≤ 0.01). In blinded testing and after at-home use, patients rated the 5-bevel needle as acceptable. After shortterm home use, patients rated the 5-bevel PN less painful and preferable to their usual PN (both p < 0.01). In paired, informed testing, the 5-bevel PN was less painful and preferred to subjects' currently used needles (p ≤ 0.01) and to other marketed PNs (p < 0.01). CONCLUSIONS Needle tip geometry affects penetration force. When blinded, patients did not distinguish differences in PN tip geometry with fine-gauge PN insertions. A 5-bevel needle tip is perceived as less painful and is preferred by subjects following home use for usual injections. Similar results occurred when patients were informed that they were using a needle with a modified tip.
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Affiliation(s)
- Laurence Hirsch
- BD (Becton, Dickinson and Company), Franklin Lakes, New Jersey, USA.
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