Results and analysis of the 2008-2009 Insulin Injection Technique Questionnaire survey

Insulin Injection Technique and Related Complications in Patients With Diabetes in a Northwest City of China

OBJECTIVES

Appropriate insulin injection technique can help to enhance positive clinical outcomes in insulin-treated patients. This cross-sectional survey was undertaken to assess the present state of injection technique practices of patients administering insulin and the incidence of local complications associated with insulin injection.

METHODS

This cross-sectional study was conducted at 11 tertiary hospitals in Xi'an City. A total of 1370 patients with diabetes were enroled in the survey. Each patient was asked questions on the Injection Technique questionnaire, demonstrated insulin injection on an injection training pad and had their injection sites inspected by a nurse.

RESULTS

About 98% of participants were type 2 diabetic patients. The 5 mm length needles were used by 640 (46.71%) patients. Around 1286 participants reused pen needles. Only one-third of patients rotate the injection sites. Around 901 patients had ecchymosis at injection sites, 43 participants suffered rash and or pruritus and 661 patients had lipohypertrophy. About 2.99% of patients reported having infection at the injection sites. Most patients (72.55%) occasionally felt pain when injecting insulin. The results of the multivariable logistict analysis showed that gender (male), needle length, priming the pen before injections and correct site rotation were negatively associated with the incidence of injection site ecchymosis. Lower incidence of lipohypertrophy was associated with needle length 4 mm, needle length 6 mm, single use of pen needles, priming the pen before injections and correct site rotation. Higher incidence of injection site infection was related to not disinfecting injection sites before each injection.

CONCLUSIONS

Despite some improvements detected in some aspects of patients' insulin injection practice in recent years, a large gap still exists between insulin injection guidelines and patients' actual injection behaviour. Injection-related complications at injection sites are still considerably common among our study population. Patients' education regarding insulin injection technique should be conducted repeatedly and regularly to make sure patients' compliance to injection guidelines.

Assessing Barriers and Adherence to Insulin Injection Technique in People With Diabetes: Development and Validation of New Assessment Tools

BACKGROUND

The correct injection technique is crucial for people with insulin therapy. However, barriers to insulin injections exist, which can lead to problems with injections. In addition, injection behavior may deviate from recommendations leading to lower adherence to the correct injection technique. We developed two scales to assess barriers and adherence to the correct technique.

METHODS

Two item pools were created to assess barriers to insulin injections (barriers scale) and adherence to the correct technique (adherence scale). In an evaluation study, participants completed the two newly created scales, as well as other questionnaires used for criterion validity. Exploratory factor analysis, correlational analysis, and receiver operating characteristics analysis were computed to analyze the validity of the scales.

RESULTS

A total of 313 people with type 1 and type 2 diabetes using an insulin pen for insulin injections participated. For the barriers scale, 12 items were selected achieving a reliability of 0.74. The factor analysis revealed three factors namely emotional, cognitive, and behavioral barriers. For the adherence scale, nine items were selected achieving a reliability of 0.78. Both scales showed significant associations with diabetes self-management, diabetes distress, diabetes acceptance, and diabetes empowerment. Receiver operating characteristics analysis showed significant area under the curves for both scales in classifying people with current skin irritations.

CONCLUSIONS

Reliability and validity of the two scales assessing barriers and adherence to insulin injection technique were demonstrated. The two scales can be used in clinical practice to identify persons in need of education in insulin injection technique.

Design and Testing of a Smartphone Application for Real-Time Tracking of CSII and CGM Site Rotation Compliance in Patients With Type 1 Diabetes

INTRODUCTION

Glycemic control in patients with type 1 diabetes can be difficult to achieve. One critical aspect of insulin delivery is site rotation, which is necessary to reduce dermatologic complications of repeated insulin infusion. No current application is designed to help patients track sites and instruct on overused sites.

OBJECTIVE

The objectives of this study were to (1) design a smartphone app, Insulin Site Guide, to gather real-time information on continuous subcutaneous insulin infusion (CSII) and continuous glucose monitor (CGM) site location and rotation compliance and instruct subjects on the use of an overused site; (2) conduct a usability study to measure site rotation compliance; and (3) report subject satisfaction with the app.

DESIGN

The app is installed on the subject's smartphone. Subjects use the app to record CSII and CGM placement in real-time. Data are sent to the study team at the end of the study. Subjects complete a questionnaire concerning the app.

RESULTS

We report site rotation compliance data for eight subjects and survey responses for 10 subjects. Initial data from eight subjects indicate a high site rotation compliance of 84% for insulin pumps. In general, the majority of users indicate high satisfaction with the app.

CONCLUSIONS

Insulin Site Guide is a mobile app that uses a novel algorithm to better guide site rotation. Use of the app has the potential to improve site rotation and decrease dermatologic complications of diabetes with long-term use.

Optimising Insulin Injection Techniques to Improve Diabetes Outcomes

The effectiveness of therapy in patients with diabetes depends on the correct use of the insulin injection technique. However, despite many established recommendations and evidence that an effective insulin injection technique is essential to improve glycaemic control and minimise the risk associated with diabetes, there is still a need to identify impediments to the insulin injection technique among patients and create awareness among patients and healthcare professionals about the importance of the optimisation of insulin injection techniques. This review focuses on the recent advancements in delivery devices, insulin injection technique teaching methods, monitoring, and complication management and highlights regional best practices and recommendations for optimising injection techniques to improve diabetes outcomes.

Investigation of appropriate needle length considering skin thickness with the real injection posture for insulin injections in diabetic patients

BACKGROUND

Insulin treatment is widely used not only for type 1 but also for type 2 diabetes patients. Insulin must be injected into the subcutaneous tissue to be effective. The needle length has been shortened for safety and efficiency. However, whether patients use an appropriate needle length is unclear.

METHODS

Skin thickness was measured by ultrasound with patients in their usual posture during injection. Furthermore, the effect of the intervention in which the needle length was changed was investigated.

RESULTS

Thirty-eight percent of the patients had fluid leakage and injected the needle intradermally. The average skin thickness was 3.3 mm while sitting, which was greater than that in a previous report including measurements taken while lying down. Consequently, the skin thickness was > 4 mm in 9.5% of the patients who used 4-mm needles. Cases of leakage and intradermal injection decreased when the needle length was changed.

CONCLUSIONS

This study identified that the needle length should be considered in patients with thick skin or a lower body mass index due to possibility of intradermal injection.

The Nuances Surrounding Insulin Prescribing

Knowledge of and expertise in insulin prescribing is crucial for health care providers who care for people with diabetes. This article reviews the available insulin preparations, how they are packaged, and nuances related to storage and use that inform the prescribing of this life-saving medication for patients. Insulin prescribing that is done correctly will save time and reduce problematic errors that could put patients at risk.

Pharmacokinetic and Pharmacodynamic Characteristics of Insulin Icodec After Subcutaneous Administration in the Thigh, Abdomen or Upper Arm in Individuals with Type 2 Diabetes Mellitus

BACKGROUND AND OBJECTIVE

Individuals with diabetes mellitus may prefer different body regions for subcutaneous insulin administration. This trial investigated whether choice of injection region affects exposure and glucose-lowering effect of once-weekly basal insulin icodec.

METHODS

In a randomised, open-label, crossover trial, 25 individuals with type 2 diabetes received single subcutaneous icodec injections (5.6 U/kg) in the thigh, abdomen or upper arm (9-13 weeks' washout). Pharmacokinetic blood sampling occurred frequently until 35 days post-dose. Partial glucose-lowering effect was assessed 36-60 h post-dose in a glucose clamp (target 7.5 mmol/L). Steady-state pharmacokinetics following multiple once-weekly dosing were simulated using a two-compartment pharmacokinetic model.

RESULTS

Total icodec exposure (area under the curve from zero to infinity after single dose; AUC_0-∞,SD) was similar between injection in the thigh, abdomen and upper arm (estimated AUC_0-∞,SD ratios [95% confidence interval]: abdomen/thigh 1.02 [0.96-1.09], p = 0.473; upper arm/thigh 1.04 [0.98-1.10], p = 0.162; abdomen/upper arm 0.98 [0.93-1.05], p = 0.610). Maximum icodec concentration (C_max) after single dose was higher for abdomen (by 17%, p = 0.002) and upper arm (by 24%, p < 0.001) versus thigh. When simulated to steady state, smaller differences in C_max were seen for abdomen (by 11%, p = 0.004) and upper arm (by 16%, p < 0.001) versus thigh. Geometric mean [coefficient of variation] glucose-lowering effect 36-60 h post-dose was comparable between the thigh (1961 mg/kg [51%]), abdomen (2130 mg/kg [52%]) and upper arm (2391 mg/kg [40%]).

CONCLUSION

Icodec can be administered subcutaneously in the thigh, abdomen or upper arm with no clinically relevant difference in exposure and with a similar glucose-lowering effect.

CLINICALTRIALS

GOV IDENTIFIER

NCT04582448.

Lipohypertrophy prevalence and its associated risk factors in insulin-treated patients with type 2 diabetes in North Borneo, Malaysia

Background

Insulin-treated diabetes patients are at high risk of developing lipohypertrophy, which can negatively impact treatment outcomes. Early detection of lipohypertrophy is crucial to preventing blood glucose fluctuation. Unfortunately, this clinical issue is often overlooked by nurses, causing the development of vascular complications, which leads to an increase in the morbidity and mortality of the type 2 diabetes mellitus population.

Objective

This study was conducted to identify lipohypertrophy prevalence and to establish the association between the presence of lipohypertrophy and its associated risk factors, including years on injection, total injection in a day, total insulin unit per day, often change needle, insulin injection site and move to a different area.

Methods

This cross-sectional study included 128 patients with type 2 diabetes mellitus who received insulin therapy in an outpatient diabetic clinic. Questionnaires on socio-demographic and lipohypertrophy-associated risk factors were distributed among patients, and lipohypertrophy-assessment was done using a checklist. Descriptive statistics and Pearson Chi-square were used for statistical analysis.

Results

The prevalence of lipohypertrophy was 51.6% (95% CI: 42.6, 60.5). Swelling on fatty tissue (46.1%) exhibited the highest percentage of lipohypertrophy features during the assessment. Pearson Chi-Square revealed a significant relationship between the presence of LH and BMI categories (χ2 = 10.059, df = 3, p = 0.018), duration of injection (χ2 = 15.001, df = 3, p = 0.002), frequency of needle replacement (χ2 = 9.525, df = 3, p = 0.023) and rotation of injection site (χ2 = 5.914, df = 1, p = 0.015).

Conclusion

The high prevalence of lipohypertrophy indicates a need for a prevention strategy. Thus, nurses should play an important role in educating patients regarding the proper administration of insulin injections and performing a routine lipohypertrophy assessment and health education on the correct method of insulin injection.

Glucagon-Like Peptide 1 Receptor Agonists Have the Potential to Revolutionize the Attainment of Target A1C Levels in Type 2 Diabetes-So Why Is Their Uptake So Low?

A target A1C of <7% is the recommended goal for most people with type 2 diabetes. However, many are not achieving this target with their current treatment. Glucagon-like peptide 1 (GLP-1) receptor agonists are highly efficacious in achieving glycemic control and could aid primary care providers (PCPs) in getting patients to their A1C target. However, despite their potential, use of GLP-1 receptor agonists in the primary care setting is limited. This review provides guidance for PCPs on how to help patients achieve their glycemic target and overcome perceived barriers of GLP-1 receptor agonist use, with the overall goal of improving PCP confidence in prescribing these agents.

The Impact of Insulin-Induced Lipodystrophy on Glycemic Variability in Pediatric Patients with Type 1 Diabetes

Lipodystrophy is the most common dermatological complication in patients with diabetes on insulin therapy. Despite the high frequency of lipodystrophy, there are still several difficulties in giving advice about avoidance into practice among children and adolescents with type 1 diabetes and their caregivers. This cross-sectional study aims to evaluate the prevalence of insulin-induced lipodystrophy in a cohort of pediatric patients with type 1 diabetes, to identify associated clinical factors and to assess its influence on glycemic control. Two hundred and twelve patients attending our Diabetes Center during a three-month period were enrolled. The presence of lipodystrophy was assessed by inspection and palpation procedures. Demographic and clinical data including type of treatment, frequency of rotation of insulin administration sites, and glucose metrics of the previous 30 days were assessed and statistically analyzed. Prevalence of lipohypertrophy was 44.3%. Two patients were affected by lipoatrophy (0.9%). Improper rotation of insulin administration sites and low awareness on lipodystrophy were associated to the occurrence of this skin condition (p = 0.050 and p = 0.005, respectively). When comparing patients with and without lipodystrophy, a significant difference in glycemic variability parameters was detected (p = 0.036 for coefficient of variation, p = 0.029 for standard deviation score of glucose levels). Lipodystrophy still represents a common complication in patients on insulin therapy. The present study reveals its negative impact on glycemic variability. This finding emphasizes the importance of prevention strategies to minimize the occurrence of this dermatological complication that may interfere with clinical history of the disease.

Gender Differences in Prevalence and Clinical Correlates of Lipohypertrophy in Insulin-Exposed Patients with Diabetes Mellitus

PURPOSE

The purpose of this systematic review was to assess potential gender differences in prevalence and clinical relevance of insulin-related lipohypertrophy (LH).

PATIENTS AND METHODS

Five electronic databases (PubMed, Embase, CNKI, Wanfang and VIP) were systematically searched for studies, from inception to 1st Sep 2022, on the prevalence of insulin-related LH. The eligibility of articles was independently screened, and the included studies were evaluated using standardized quality assessment tools.

RESULTS

A total of 22 studies mentioned the LH prevalence in different genders, of which two are about gestational diabetes; therefore, 20 studies were eventually included, providing data on 6238 patients. The prevalence of LH varied from 30.26% to 72.54%. Ten studies (4392 patients) were conducted with the adult diabetes patients of different genders over the age of 18, the total prevalence rate of LH was 51.73%, the LH prevalence in male gender was from 41.94% to 68.57% and the rate of the total population was 54.89% (2046 patients); The LH prevalence in female gender was from 33.18% to 70% and the rate of the total population was 48.98% (2346 patients), and the prevalence of LH was significantly different between male and female gender (P<0.001). Interestingly, only one study (n=1227) showed that there were dramatic differences between different genders (P<0.001), the subjects were T2DM patients, the LH prevalence rate of male vs female was 70.52% (299/424) VS 52.18% (419/803), while the other studies either only include T1DM or both T1DM and T2DM.

CONCLUSION

The evidence shows that the results of gender differences in the LH prevalence are inconsistent with different types of DM. Probably, there is no gender differences in the LH prevalence in adult patients with T1DM, but it has a gender difference between male and female in T2DM. More strictly designed clinical studies are needed to further verify and reveal the underlying mechanisms.

Insulin-induced Lipohypertrophy in Patients with Type 1 Diabetes Mellitus Treated with an Insulin Pump

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, HbA_1c 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.

Skin Involvement in Paediatric Patients with Type 1 Diabetes

Skin involvement is an overlooked aspect in the management of paediatric patients with type 1 diabetes. A comprehensive search of published literature using the PubMed database was carried out using the following key terms: "children," "pediatric/paediatric patients," "skin," "skin disorders," "type 1 diabetes." Dermatological side effects are frequently observed among diabetic children and adolescents. Insulin-induced lipodystrophies and allergic contact dermatitis caused by insulin pumps or glycaemic sensors are the most common skin reactions in these patients. Furthermore, several diabetes-associated skin diseases such as necrobiosis lipoidica, granuloma annulare, vitiligo, and bullosis diabeticorum may already be present in paediatric patients. Paediatric diabetes specialists should pay attention to their patients' skin to recognize these disorders, identify the potential causes, and choose the most suitable treatment. Finally, the evaluation of skin concentrations of advanced glycation end-products using non-invasive diagnostic techniques may be used to assess the risk of chronic complications of diabetes as early as adolescence.

A Systematic Survey of Physicians' Insights Into Lipohypertrophy

Background: It is important that physicians be aware of LH. We designed a questionnaire to determine physician awareness, knowledge, and behaviors regarding LH in clinical practice.

Participants: A total of 499 questionnaires were completed by physicians in hospitals from 13 cities in Jiangsu Province, China.

Key Results: Compared with physicians at tertiary hospitals, significantly fewer physicians at primary hospitals reported awareness of LH and its screening methods. The proportion of resident physicians aware of LH was significantly lower than the proportion of senior physicians. The proportion of physicians who could identify all LH risk factors among the low-GDP group was significantly higher than the high-GDP group. Only 38.7% of doctors could successfully identify all the hazards associated with LH, but more doctors in tertiary hospitals were able to do so compared to those in secondary and primary hospitals. Compared with tertiary hospitals, the proportions of primary and secondary hospitals with management processes were significantly lower. The proportion of doctors who educated patients regarding LH prevention and treatment in primary hospitals was markedly lower than in tertiary hospitals.

Conclusions: Overall, physicians have an inadequate understanding of LH, especially in primary hospitals.

Characteristics and morphology of lipohypertrophic lesions in adults with type 1 diabetes with ultrasound screening: an exploratory observational study

INTRODUCTION

Lipohypertrophy is a common complication of exposure to insulin therapy. Despite the prevalence of lipohypertrophy and its potentially hazardous effects on glucose regulation, it remains a relatively understudied problem in diabetes. The objective of this study was to characterize lipohypertrophic tissue using ultrasound in adults with type 1 diabetes.

RESEARCH DESIGN AND METHODS

An observational study of 74 people with type 1 diabetes from a diabetes center in South East London. Participants' insulin exposed areas were scanned with ultrasound, with a high-frequency linear probe (6-13 MHz). The observed tissue changes were described, measured and graded according to nodule size and thickness of the dermal layer.

RESULTS

Participants mean age and diabetes duration were 40.6 (±14.2) and 18.3 (±10.9) years, respectively, and 60% (n=44) were male. A total of 740 lipohypertrophic nodules were observed, ranging from 1.8 mm to 40 mm in width. The mean (SD/range) number of nodules per participants was 10.4 (±6.2/1-29). Delineation between the dermal layers was disrupted in all current injection sites. In 52 participants (70%), there was a 30% increase in dermal thickness compared with local none injected tissue, and in 36 participants (48%) the increase was 50%. The level of thickness was >3 mm in the abdominal areas of 22 (40%) of these participants and in thighs of eight participants (17.8%). Hypoechogenic areas suggestive of necrotic tissue were observed within the lipohypertrophic nodules of 22 (30%) participants. Needle length and nodule depth were correlated (r=0.69, p<0.001). A conceptual model of the insulin exposed tissue changes observed was constructed.

CONCLUSIONS

The study confirms that insulin-exposed tissue changes are heterogenous and has provided conceptual and grading frameworks for classifying these changes. Further studies are required to establish the clinical implications of these classifications, in relation to glucose regulation and other clinical parameters.

Local complications of insulin administration sites and effect on diabetes management

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.

Early detection of cutaneous complications of insulin therapy in type 1 and type 2 diabetes mellitus

BACKGROUND

Subcutaneous insulin therapy is associated with important injection site complications, which can influence insulin pharmacokinetics resulting in glycemic fluctuations above and below target levels for blood glucose.

OBJECTIVE

Our objective was to assess the prevalence and risk factors of cutaneous complications including insulin derived amyloidosis in insulin-injecting diabetes patients and to study the role of ultrasonography (in comparison to gel-assisted palpation) in early diagnosis of lipohypertrophy (LH).

METHODS

This was a cross-sectional study conducted at a tertiary care center in India, wherein 500 patients injecting insulin for ≥2 years were randomly enrolled and evaluated for the presence of cutaneous complications of insulin therapy through clinical examination, ultrasonography and punch biopsy of skin.

RESULTS

Clinical examination detected LH in 44.6% of patients. Ultrasonography diagnosed additional 13.4% of patients with LH which were missed on clinical examination. Incorrect rotation of sites (P < 0.001) and insulin syringe reusage for more than five times (P < 0.001) significantly increased the risk of LH. Skin biopsy was performed in 100 cases, out of which two patients showed apple green birefringence and its association with insulin was confirmed by positive staining with anti insulin antibody in these two patients.

CONCLUSION

Improper rotation of sites and reuse of needles were the leading causes of LH in Indian diabetic patients. Ultrasonography is more objective and reliable method of detecting LH. Insulin-derived amyloidosis may be a more common complication of insulin therapy than previously thought.

Impact of pharmacist insulin injection re-education on glycemic control among type II diabetic patients in primary health clinics

Background

Insulin injection technique re-education and diabetes knowledge empowerment has led to improved glycemic control.

Objectives

To evaluate the impact of pharmacist's monthly re-education on insulin injection technique (IT), lipohypertrophy, patients' perception on insulin therapy and its effect on glycaemic control.

Methods

This randomized controlled, multi-centered study was conducted among type 2 diabetics from 15 government health clinics. 160 diabetics with baseline HbA1_C ≥ 8% and unsatisfactory IT technique were randomized into control or intervention group. Control group received standard pharmacist counselling during initiation and at 4th month. Intervention group received monthly counselling and IT re-education for 4 months. Assessment of diabetes, IT knowledge, adherence and perception towards diabetes were conducted using validated study tools Insulin Treatment Appraisal Scale (ITAS) and Medication Compliance Questionnaire (MCQ)).

Results

139 patients completed the study; control group (69), intervention group (70). In control group, all outcomes shown improvement except for patient's perception. Mean HbA1_C decreased 0.79% ± 0.24 (p = 0.001). In intervention group, all outcomes improved significantly. HbA1c reduces significantly by 1.19% ± 0.10 (p < 0.001). Monthly re-education improved patient's perception towards insulin therapy (ITAS score reduced 1.44 ± 2.36; p = 0.021). Between groups, interventional arm shown significantly better improvement in all outcomes. Improvement was shown in IT technique (+2.02 score; p < 0.001), medication adherence (+1.48 score; p < 0.001) and ITAS (-1.99 score; p = 0.037). Mean HbA1_C reduced an additional of 0.63% (p = 0.008) compared to control arm.

Conclusion

Re-education is more effective in increasing adherence, reducing lipohypertrophy, improving injection technique and patient's perception on insulin therapy, thereby providing better glycaemic control.

A meta-analysis and meta-regression on the prevalence of lipohypertrophy in diabetic patients on insulin therapy

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, HbA_1c, 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.

Study on the effect of education for insulin injection in diabetic patients with new simulation tools

BACKGROUND

Insulin is an essential therapy for treating diabetes, but many patients lack standard insulin injection skills.

PURPOSE

We developed a standard training procedure based on a new simulation tool. Then we conducted a study to investigate the effect of this standard training on the ability of diabetic patients to inject themselves with insulin.

METHODS

After follow-up, a total of 120 patients with diabetes mellitus were included. These patients needed insulin therapy depending on their condition and had not previously learned insulin injection. We randomly divided them into the intervention group (60 cases) and the control group (60 cases). The control group was trained on insulin injection before being discharged according to the traditional method, and the intervention group was trained based on an improved simulation tool. All participants were trained as individuals or groups. Finally, we evaluated the learning effects of both groups.

RESULTS

The time spent at the training stage in the intervention group was shorter than the control group. We found that after applying simulation devices to mimic operations, the learning time for patients was reduced.The first subcutaneous injection success rate was 73.33% in the intervention group, which was significantly higher than that in the control group by 46.67%. The score of the first subcutaneous injection and pre-discharge score in the test group was significantly higher than that of the control group. One month later, the score for injection skills in the 2 groups was higher than that before discharge, and the score in the trial group was still higher than that in the control group. The incidence of subcutaneous fat hyperplasia in the trial group was lower than that in the control group (3.3% vs 15%, P < .05). Moreover, the incidence of hypoglycemia (16.7% vs. 26.7%) was higher in the control group, but the difference was not statistically significant (P = .184).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

After applying simulation tools plus operating video and guideline as the standard procedure to train diabetic patients on insulin injection, all patients had a good grasp of using the insulin injection technique. This education method is safe, efficient, and worth promoting worldly.

Bruising: A Neglected, Though Patient-Relevant Complication of Insulin Injections Coming to Light from a Real-Life Nationwide Survey

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.

Oral Coadministration of Zn-Insulin with d-Form Small Intestine-Permeable Cyclic Peptide Enhances Its Blood Glucose-Lowering Effect in Mice

Oral delivery of insulin remains a challenge owing to its poor permeability across the small intestine and enzymatic digestion in the gastrointestinal tract. In a previous study, we identified a small intestine-permeable cyclic peptide, C-DNPGNET-C (C-C disulfide bond, cyclic DNP peptide), which facilitated the permeation of macromolecules. Here, we showed that intraintestinal and oral coadministration of insulin with the cyclic DNP derivative significantly reduced blood glucose levels by increasing the portal plasma insulin concentration following permeation across the small intestine of mice. We also found that protecting the cyclic DNP derivative from enzymatic digestion in the small intestine of mice using d-amino acids and by the cyclization of DNP peptide was essential to enhance cyclic DNP derivative-induced insulin absorption across the small intestine. Furthermore, intraintestinal and oral coadministration of insulin hexamer stabilized by zinc ions (Zn-insulin) with cyclic D-DNP derivative was more effective in facilitating insulin absorption and inducing hypoglycemic effects in mice than the coadministration of insulin with the cyclic D-DNP derivative. Moreover, Zn-insulin was more resistant to degradation in the small intestine of mice compared to insulin. Intraintestinal and oral coadministration of Zn-insulin with cyclic DNP derivative also reduced blood glucose levels in a streptozotocin-induced diabetes mellitus mouse model. A single intraintestinal administration of the cyclic D-DNP derivative did not induce any cytotoxicity, either locally in the small intestine or systemically. In summary, we demonstrated that coadministration of Zn-insulin with cyclic D-DNP derivative could enhance oral insulin absorption across the small intestine in mice.

Knowledge, attitude and practice towards insulin self-administration and associated factors among diabetic patients at Zewditu Memorial Hospital, Ethiopia

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.

Insulin injection practices among youngsters with diabetes in Tikur Anbesa Specialized Hospital, Ethiopia

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.

Aplicação de insulina passo a passo: construção de vídeos educativos para pacientes e cuidadores

RESUMO Objetivo descrever o processo de construção, avaliação e adequação de vídeos educativos sobre aplicação de insulina direcionados a pacientes adultos e cuidadores. Método estudo metodológico, de caráter descritivo, realizado em três fases: construção, avaliação e adequação. A construção dos vídeos foi realizada com base em revisão de literatura e no protocolo do município. A avaliação foi realizada com experts, por meio de um instrumento construído pelos pesquisadores. O nível de concordância entre os experts foi avaliado pelo índice de validade do conteúdo, que orientou o processo de adequação do material. Resultados os vídeos foram construídos contemplando os principais pontos críticos relacionados à aplicação de insulina. Os itens que obtiveram índice de validade de conteúdo < 0,8 foram reformulados. Conclusão e Implicações para a prática foram produzidos dois vídeos que abordam o transporte, armazenamento, preparo e aplicação da insulina, descarte de perfurocortantes e monitorização da glicemia. Os vídeos educativos construídos podem ser considerados ferramentas facilitadoras do processo de educação em diabetes mellitus e úteis na uniformização de orientações. A descrição do processo de construção, avaliação e adequação pode encorajar outros profissionais a desenvolver materiais que respondam às necessidades de seus contextos de trabalho e assim melhorar e qualificar o cuidado às pessoas.

Insulin injection technique in the western region of Algeria, Tlemcen

Introduction

Algeria has more than 1.7 million diabetic patients on to whom a descriptive assessment particularly on the insulin usage behaviors has not yet been initiated, although is needed. This study aims to provide a descriptive analysis of how Algerian diabetic patients perceive and apply insulin injection techniques.

Methods

using the “patient” questionnaire within the Injection Technique Questionnaire (ITQ) 2016 survey, this study assessed the insulin injection practices of 100 patients recruited over a seven-month period in western Algeria at the Tlemcen University Hospital Center. The results of this study are compared to those of the ITQ 2016 survey.

Results

pens are the instruments of injection for 98% of Algerians who continue to use mostly long needles of 6- and 8-mm, although 4mm needles are the recommended safer option. Insulin analogues (fast and basal) are plebiscite. Arms and thighs are the preferred injection sites; the abdomen (the preferred site elsewhere) is neglected for reasons to be investigated. The correct re-suspension technique for cloudy insulin is unknown. Extensive pen needle re-use (10+ times) for over half of the patients exposes them to both higher intramuscular (IM) injection risk and lipohypertrophy (LH). Injection training is performed in Algeria by the diabetologist.

Conclusion

this study describes for the first time Algerian patients´ insulin injection technique. It highlights their skills and identifies many deficiencies which patients and professionals must correct given the issues in this area.

Insulin Injection Practices in a Population of Canadians with Diabetes: An Observational Study

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.

Insulin-Induced Skin Lipohypertrophy in Type 2 Diabetes: a Multicenter Regional Survey in Southern Italy

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.

Evaluation of Antidiabetic Injectable Technique: Is There an Association between Accuracy and Health Literacy or Duration of Diabetes?

Introduction:

Effective diabetes pharmacotherapy often involves injectable medications, which if used inappropriately represents a type of unintentional medication nonadherence that leads to poor outcomes.

Objectives:

The primary objective of this study was to assess the percent of patients who accurately prepared, administered, stored, and disposed of their injectable diabetes medication. Secondary objectives included comparing the accuracy of injectable use among those with diabetes <5 years vs. ≥ 5 years duration and those with limited vs. proficient health literacy.

Methods:

This was a prospective analysis conducted on a convenience sample of patients who received a pilot pharmacist-led, quality improvement service at an urban, ambulatory care clinic. The service components included health literacy screening, using the Rapid Assessment of Adult Literacy in Medicine – Short Form (REALM-SF) tool, evaluation of injectable technique by use of a standardized questionnaire, and provision of medication education. Duration of diabetes was determined by patient self-report. Chi-square and Fisher’s exact tests were utilized to assess accuracy of injectable technique in two group comparisons: (1) patients with limited vs. proficient health literacy and (2) patients with diabetes <5 years vs. ≥5 years.

Results:

Thirty-five patients were included in the analysis. Despite the majority (71.4%) of patients reporting prior education on injectable use, 54.3% reported at least one error in product use. Significant findings noted were that those with limited health literacy had higher rates of accurately using the skin-fold technique and appropriate angle for injection vs. those with proficient health literacy (p<0.05 for both comparisons). Likewise, more patients in the cohort of diabetes duration ≥5 years accurately rotated the injection site vs. those with a duration <5 years (p=0.001).

Conclusion:

Errors in injectable technique were common in this study and spanned across health literacy levels and duration of diabetes. Patients prescribed injectable diabetes medications should be routinely educated on proper technique for use.

Improved insulin injection technique, treatment satisfaction and glycemic control: Results from a large cohort education study

•

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.

Prevalence, Risk Factors, and Clinical Characteristics of Lipodystrophy in Insulin-Treated Patients with Diabetes: An Old Problem in a New Era of Modern Insulin

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.

Frequency of injection site assessment for lipohypertrophy in children and young people with type 1 diabetes

Children and young people with diabetes are at high risk of developing lipohypertrophy (LH) as a result of daily injections of insulin. LH is characterised by dense nodules that are palpable beneath the skin's surface. A retrospective audit investigated the frequency of injection site assessment in children and young people attending a diabetes clinic over one year. The audit was conducted using the medical records of 76 eligible patients with type 1 diabetes, all treated with multiple daily injections or continuous subcutaneous insulin infusions for a minimum of six months from the audit start date. None of the participants had their injection sites assessed at every clinic visit. Just under one third ( n =23, 30%) received at least one injection site assessment within the audit year. Of these, 11 had LH detected. HbA 1c and average blood glucose levels were higher in those with LH, which was deemed significant. There was a slight increase in glucose variation in those with LH compared with those without LH. However, this result was not statistically significant. The frequency of injection site assessment is low in children and young people but the prevalence of LH is high. This means it is essential to improve healthcare professionals' injection technique education and assessment skills to minimise the risk of patients developing LH.

Insulin-Related Lipohypertrophy in Hemodialyzed Diabetic People: a Multicenter Observational Study and a Methodological Approach

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.

The Injection Technique Factor: What You Don't Know or Teach Can Make a Difference

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.

Insulclock: A Novel Insulin Delivery Optimization and Tracking System

BACKGROUND

Achieving and maintaining controlled glycemic levels are challenging in people with insulin-treated diabetes mellitus, suboptimal insulin injections being the main obstacle to treatment success.

METHODS

This research article presents the main functionalities and performance tests on Insulclock^®, an electronic device plugged into insulin pens and connected with a smartphone app to improve insulin management. Insulclock tracks the date, time of day, dose, type of insulin, temperature, and duration of insulin injections. Information is stored in the device memory and is available for analysis by patients and health care providers. Insulclock device also has a reminder system with visual and acoustic alerts to reduce insulin omissions and mistiming.

RESULTS

The main performance tests reveal that Insulclock can detect seven types of insulin pens with a 97% correct classification rate. Among 556 injections, most of the doses were accurately detected (deviation = 0), with relative errors ranging from 3% to 7% across different dosages. The duration of injections recorded by this device strongly correlated with that detected by an external chronometer (R² = 0.99, root-mean-square deviation [RMSD] = 0.39). Moreover, the precision of the temperature sensor was evidenced by high correlation of temperatures detected by Insulclock and by an external thermometer (Pearson's R² = 0.90, RMSD = 0.45).

CONCLUSIONS

Insulclock is a novel device capable of tracking dosing, timing, and missing insulin injections. The promising capabilities it offers for diabetes mellitus self-management may help health care providers, researchers, and insulin users avoid frequent errors in insulin administration.

Do patients with diabetes use the insulin pen properly?

AIM

This study was conducted to evaluate the insulin pen application knowledge and skills of patients with diabetes.

METHODS

In our descriptive study, 200 patients with diabetes were asked to present the insulin pen injection technique on a mannequin and the steps of the pen injection implementation were noted on the data collection form as correct/incorrect by researchers.

RESULTS

More than 3 out of 4 (79.5%) of the participants were using the insulin pen or the cartridge after the expiry date, 70.5% were not rotating the injection site, and 63.0% were massaging the skin after injection. Injection sites complications were significantly more in those who were using the insulin pen or the cartridge after the expiry date, those who don't know the proper length of the needle and the possible body injection sites, those who don't rotate the injection sites, those who massage after injection, and those who don't use a new needle at each injection (p<0.05).

CONCLUSION

This study put into light some failures in the knowledge and skills of patients with diabetes regarding insulin pen use. Nurses should provide patients with diabetes an effective and repetitive training concerning insulin pen use.

Competency of Prefilled Insulin Pen Usage Among Diabetes Patients in Saudi Arabia: A Cross-sectional Study

BACKGROUND

Correct insulin injection practice is essential for better diabetic control. The aim of this study is to investigate the level of competency of prefilled insulin pen usage (injection technique and storage) among diabetes patients in Saudi Arabia.

METHODS

A cross-sectional survey between March 2017 to July 2017 of randomly selected patients with diabetes attending Diabetes Treatment Center, Prince Sultan Military Medical City, Saudi Arabia, who are actively using a prefilled insulin pen, were interviewed to complete a pre-structured questionnaire to assess the competency of using the insulin pen. The contents of the questionnaire addressed the 6 competency components according to manufacturer recommendation (priming, count time, storage, using new needles, a store with no needles, and discard date), background, clinical and metabolic data. Results of the questionnaire were analyzed to identify common pitfalls and were also contrasted with background clinical and metabolic data.

RESULTS

165 patients with diabetes (aged 14-70yrs) were interviewed for the study and all questioners completed properly. Only 14 (8.5%) patients were following all of the six competency components. Count time 52 (31.6%) was the least followed competency component of the six, whereas discard date and storage of insulin pen were the most followed with 165 (100%) and 159 (96.4%), consecutively. Education was the only significant variable related to the following more than 3 of the competency components, and logistic regression showed the college or higher educated patients to be three times more likely follow more than 3 of the competency components.

CONCLUSION

The study concluded that majority of patients are either ignoring or unaware of the major components of correct use of prefilled insulin in Saudi Arabia.

Insulin Injection Technique in China Compared with the Rest of the World

INTRODUCTION

Approximately 9 million people in China use insulin but little is known of their injection techniques (IT). Our aim was to understand IT in China via direct examination and a detailed survey.

METHODS

Injection Technique Questionnaire (ITQ) results of 3853 patients from 20 representative centers in China were compared with the Rest of World (ROW).

RESULTS

Insulin pens are used by 92% of Chinese insulin injectors, with > 3/4 using 4- or 5-mm pen needles. This is consistent with Chinese BMI values (and thus subcutaneous fat thickness) being lower than in ROW, raising the risk of IM (intramuscular) injections with longer needles. Total daily insulin dose is ~ 33 IU in China vs. 45 IU elsewhere. Lipohypertrophy (LH) rates are lower than in ROW, but still found in at least 25% of Chinese patients. Patients apparently do not realize they have LH or are unaware of the hazards of injecting into LH since many of them do so, and those who do use a mean of 11 IU more of insulin than non-LH patients. This incremental insulin use possibly costs the Chinese health care service around 2 billion RMB annually. Needle reuse is also frequent in China (78% vs. 48% ROW), and the high cost of pen needles is the main reason patients cite for reusing (25% use a single needle > 10×).

CONCLUSION

This study reveals many areas in which Chinese professionals and patients can optimize injection practices and thereby improve outcomes and reduce costs. The official guidelines of the Chinese Diabetes Society, based on the FITTER recommendations, offer a roadmap for reaching this goal.

FUNDING

BD Diabetes Care. Plain language summary available for this article.

A Systematic Review of Ultrasound-Detected Lipohypertrophy in Insulin-Exposed People with Diabetes

INTRODUCTION

Lipohypertrophy (LH) is a common complication occurring in diabetes individuals. The most common methods used include palpation, visual examination and/or ultrasound (US). To date, there is limited information on the detection sensitivity among the different techniques used to identify LH. This systematic review aimed to identify studies that examined insulin-related LH using US detection to identify the prevalence, characteristics and morphology of LH, and to compare US and clinical palpation methods for detecting LH.

METHODS

Three electronic databases were systematically searched for studies detecting LH using US in insulin users. Articles were screened for eligibility and included studies were appraised using quality assessment tools. The quality of the evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation, and the extracted data was synthesised narratively.

RESULTS

Sixteen articles were included in the review providing data on 1722 patients. The prevalence of LH prevalence varied from 14.5% to 88% (median 56.6%). Identified risk factors for the development of included insulin injection behaviour such as a lack of injection site rotation and social factors such as low education level. Four studies compared LH detection by US to palpation, providing inconsistent results. One study showed that palpation detected 64% more LH, whilst two studies demonstrated that US identified 50% more sites and extended areas of LH (additional ~ 5 cm²). Another study provided comparable estimates between palpation and US in clinicians trained to detect LH (97%).

CONCLUSION

The evidence highlights a lack of congruence in results pertaining to the detection sensitivity of US and palpation for LH sites. More research with robust study design is needed to verify whether clinically palpation is sufficient to detect LH, or whether US would increase the precision of LH assessment to help address this common clinically significant problem.

Construction and validation of a low-cost simulator for training patients with diabetes mellitus and/or their caregivers in insulin administration

Abstract Objective: The objective of this study was to construct and validate a low-cost simulator to train diabetes mellitus patients and their caregivers on the administration of insulin. Method: Action research study with a qualitative approach, through a validation methodological study. Results: A low-fidelity simulator was constructed with the areas recommended for insulin administration adapted to allow skill training. Validation was done by nine experts on the subject. Conclusions: The prototype has low cost and greater anatomical functional fidelity than the models currently available in the market. Implications for practice: The simulator developed can be used by health professionals, caregivers or by the patients themselves as a tool in the training for insulin administration. Its use may favor the identification of critical points related to the application technique, allowing the planning of more directive and effective educational interventions.

Turkish Insulin Injection Technique Study: Population Characteristics of Turkish Patients with Diabetes Who Inject Insulin and Details of Their Injection Practices as Assessed by Survey Questionnaire

INTRODUCTION

Over 7 million people in Turkey have diabetes. Of the 1 million who inject insulin little is known of their habits and injection techniques.

METHODS

We conducted an Injection Technique Questionnaire (ITQ) survey throughout Turkey that involved 1376 patients from 56 centers. Turkish values were compared with those from 41 other countries participating in the ITQ, known here as Rest of World (ROW).

RESULTS

The majority (50.4%) of Turkish insulin users give four injections/ day as opposed to ROW, where only 30.9% do. The abdomen is the most common injection site used by Turkish patients, but they also inject insulin in multiple body sites more often than do patients in ROW. Body mass index values in Turkey were 0.75 units higher than those in ROW as was the mean total daily dose (average daily dose [ADD]) of insulin (54.0 IU in Turkey vs. 47.4 IU in ROW). Mean glycated hemoglobin (HbA1c) in Turkey was 9.1%, which is higher than in ROW and possibly related to the higher BMI and ADD. Turkish patients use insulin analogs (short and long-acting) more frequently than do patients in ROW. The shortest pen needles (4 mm) are used by about one-third of patients in Turkey, but the longer ones (8 mm) are equally common. Needles are reused in Turkey at a rate of 3.4 injections/single needle. However, needle reuse, whether with pens or syringes, is lower in Turkey than ROW, as is the number of times a reused needle is used. More than 75% of used sharps in Turkey go into the rubbish, with nearly 6% having no protection of the tip.

CONCLUSION

The continued use of 8-mm needles raises the risk of intramuscular injections in Turkish patients. Despite full reimbursement, needle reuse still remains an important issue. More focus needs to be given to dwell times under the skin, reconstitution of cloudy insulant, correct use of skin folds and safe disposal of sharps.

FUNDING

BD Diabetes Care.

Turkish Insulin Injection Techniques Study: Complications of Injecting Insulin Among Turkish Patients with Diabetes, Education They Received, and the Role of Health Care Professional as Assessed by Survey Questionnaire

INTRODUCTION

Using the Turkish and rest of world (ROW) Injection Technique Questionnaire (ITQ) data we address key insulin injection complications.

METHODS

Summarized in first ITQ paper.

RESULTS

Nearly one-third of Turkish insulin users described lesions consistent with lipohypertrophy (LH) at their injection sites and 27.4% were found to have LH by the examining nurse (using visual inspection and palpation). LH lesions in the abdomen and thigh of Turkish patients are slightly smaller than those measured in ROW but more than half of Turkish patients who have LH continue to inject into them at least daily. More than a quarter of Turkish patients have frequent unexplained hypoglycemia and nearly 2 out of 5 have glycemic variability, both of which have been linked to the presence of LH and the habit of injecting into it. Nearly half of Turkish injectors report having pain on injection. Of these, just over half report having painful injections only several times a month or year (i.e., not with every injection). In Turkey the diabetes nurse has by far the major role in teaching patients how to inject. Nearly 40% of Turkish injectors get their sites checked at least annually, and a larger proportion than ROW had received recent (within the last 12 months) instruction on how to inject properly.

CONCLUSION

Turkish patients and professionals have clearly made progress in injection technique, but there are still considerable challenges ahead which the new Turkish guidelines will help address.

FUNDING

BD Diabetes Care.

Clinical Implications of Lipohypertrophy Among People with Type 1 Diabetes in India

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.

Optimizing insulin delivery for patients with diabetes

Management of diabetes for residents in long-term care settings is particularly challenging, due to the wide range of physical and mental limitations that bear on efficacy of their medications, as well as practical issues associated with the optimal administration of these medications. Foremost among the practical issues for residents requiring insulin injections, is the need to ensure that it is consistently delivered to the circulation at the target rate and dosage, thereby avoiding life-threatening episodes of hypoglycemia. Recent evidence from a multinational survey has elucidated principles of insulin injection technique, including optimal needle length and site rotation that can greatly improve consistency in delivering insulin to the subcutaneous compartment, while reducing pain, improving patient compliance, and limiting the total daily dosage. The present review consolidates these findings and highlights the most critical take-home messages for healthcare professionals working in this area.

Lipohypertrophy in Individuals with Type 2 Diabetes: Prevalence and Risk Factors

Introduction: As well as its negative effect on the subcutaneous tissues, lipohypertrophy has negative effects on clinical data. The purpose of this study was to examine the frequency of lipohypertrophy, risk factors and perceived barriers preventing rotation in individuals with type 2 diabetes.

Methods: This descriptive cross-sectional study was conducted at Diabetes Education Center and Endocrine and Metabolism Clinic of a university hospital and Diabetes Education and Monitoring Center in a private hospital in Turkey between June 2016- April 2017. The inclusion criteria were as follows; undergoing at least one year of insulin therapy, injecting insulin pens or syringes themselves, being over 18 years of age, making regular injection of insulin and being a patient with type 2 diabetes. Introductory information form was used to collect the data. The data were analyzed using descriptive statistics and chi-square analysis with SPSS version 16.0.

Results: Factors influencing lipohypertrophy development were determined as follows; healthcare personnel who provide insulin education, duration of diabetes, the number of injection administered daily, needle length, the number of injection sites, insulin types, injection site rotation and intra-site rotation and needle exchange frequency. In addition, the prevalence of lipohypertrophy was found to be higher in patients with hypoglycemia, unexplained hypoglycemia, and those with high BMI and A1C.

Conclusion: It is recommended that diabetes education should be provided by the diabetes specialist nurses who have diabetes-specific certifications and / or education and who can provide full-time education. Randomized controlled interventional studies investigating how to prevent the lipohypertrophy development are also needed.

Insulin-Related Lipohypertrophy: Lipogenic Action or Tissue Trauma?

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.