Addendum: First injection technique recommendations for patients with diabetes, Forum for Injection Techniques India

Abstract

The forum for injection techniques, India recommendation, the first ever in the country on insulin injcetion techniques, have covered the science and the art of insulin injection technique in an exhaustive manner. However, a few gaps were identified in the document, which are addressed in the current addendum. This article focuses on insulin injection technique in special clinical situations, including geriatric people, women in pregnancy and those with dermatological or surgical disease who live with diabetes. The addendum also covers salient features of administration of insulin using the insulin pump.

INTRODUCTION

The forum for injection techniques (FIT), India, published the first Indian recommendations for best practice in insulin injection technique in 2012.[1] These recommendations have received a favorable response and have been cited by various authors.[2,3,4,5]

As science is dynamic, so are the scientific recommendations. In keeping with this spirit, the core writing group of FIT India met to identify gaps and unanswered questions in the original draft. Important gaps were prioritized and hence, form the subject matter of this addendum. This addendum is written by the core group and by a co-opted member and approved by the FIT India board. It covers the following areas in insulin technique: Counseling of geriatric persons with diabetes, injection in pregnancy, dermatological disease and surgical disease and insulin pump technique.

The choice of these topics was informed by informal discussion amongst FIT board members, feedback from participants in FIT workshops conducted across India and realization that insulin usage is growing rapidly in the patient populations, described above. It was also noted that robust evidence is not available to address many of issues identified for attention.

This communication should be read in conjunction with the 2012 recommendations.[1] It is planned to review the original recommendations at regular, preferably, yearly, intervals, to assess the need for further addenda.

PRE-INJECTION COUNSELING: GERIATRICS

Counseling geriatric patients for self-injection can be a challenging task. Unlike their younger peers, they may have certain age related potential difficulty in executing the instructions for injections properly. Functional disability, depression and lack of self-motivation, impaired cognitive function, inflammatory arthropathy and motor system disorders can considerably affect the ability to administer insulin, monitor blood glucose and manage hypoglycemia. Dexterity, visual impairment, hearing impairment are of utmost importance in this vulnerable group of patients.[6,7]

The importance of modern pen devices is reflected best in the field of geriatrics. Their discreetness, simplicity and convenience of use, dosage accuracy and being less painful to inject allows for widespread acceptability amongst the elderly.[8,9,10] Easy pre-selection of the prescribed insulin dose has also been well-documented.[11]

Various guidelines for diabetes management in the elderly have discussed these points and suggested some practical remedial steps.[12] It has been suggested that the physician should not use age as an excuse to avoid usage of insulin. Technical superiority of a product (analogue vs. conventional) or an injection device (pen vs. syringes), should be given due consideration. Along with insulin initiation, all elderly patients should be taught a structured self-monitoring and algorithm based insulin dose titration. Health-care providers must ensure the involvement of responsible family members/attendants during the selection of insulin and explanation of injection technique, in case of frail and very old patients.

PREGNANCY

Insulin is required in about 10-20% of all antenatal women with diabetes, which complicates about one-sixth of all pregnancies. Patients should be reassured that insulin is not only safe in pregnancy, but also contributes to maternal and fetal well-being.

The abdomen is a safe site for insulin administration in pregnancy.

First trimester: Women should be reassured that no change in insulin site or technique is needed.

Second trimester: Lateral parts of the abdomen can be used to inject insulin, staying away from the skin overlying the fetus.

Third trimester: As mentioned in the FIT India guidelines,[1] insulin can be injected over the abdomen while ensuring the skin fold is properly raised. Apprehensive patients may use the thigh or upper arm to inject themselves.

DERMATOLOGICAL DISEASE

Insulin injection should be avoided at sites of active or recently healed infection or inflammations, such as skin and soft-tissues infections and psoriasis. Injection should not be administered in to keloids or scars. However, stable vitiligo is not a contraindication for insulin injection. Acanthosis nigricans is also not a contraindication.

Insulin can be injected in to sites of lipoatrophy, but not lipohypertrophy.

SURGICAL DISEASE

In patients with recent surgical wounds or open fistulas/ileostomies/colostomies, a different quadrant of the abdomen should be used for insulin injection. Adequate pre-injection cleansing must be done.

Apprehensive patients with recent abdominal surgery may use the high or upper arm for injection.

INSULIN PUMP INFUSION

The insulin pump is a pager-sized device, which provides continuous sub cutaneous delivery of rapid acting insulin with the help of an infusion set. One end of the infusion set connects to the reservoir, which is filled with insulin and is kept inside the insulin pump and the other end of the infusion set is connected to the needle placed subcutaneously.

In India, unlike in the Western world, pumps are more commonly used in type 2 diabetes. As an alternative delivery system, insulin pumps are a replacement for syringes/pens, provided the subject fulfills the essential criteria for a pump candidature. Since there are no reimbursement policies for pump users in India, most of the subjects have innovated and improvised their own ways and means of reducing the cost by prolonging the use of infusion sets and reusing reservoirs.

Such peculiar circumstances have created an urgent need for formulating insulin pump infusion guidelines. These need to be customized for the Indian subcontinent, considering education, ethnicity, dressing styles, resources and weather, while at the same time ensuring clinical efficacy and avoidance of infections.[13]

Infusion site

The preferred infusion site for pumps is the abdomen, while the upper arm and thighs are alternate sites. Select a site in the abdomen 5 cm away from the umbilicus and every new site should be 2.5 cm away from the previous site. Following a systematic pattern will help ensure that the longest possible time will pass before using the same site again. In pregnancy, the outer thigh or hip may be used.

Cannula selection

Plastic cannulae are preferred by almost all doctors recommending an insulin pump. Steel needle infusion sets are recommended in pregnancy, for patients who have reactions to plastic cannulae and who have frequent kinks in plastic cannulae. Short length cannulae (6 mm for 90° sets, 13 mm for 30-45° angled infusion sets) are most preferred. Shorter tubing is recommended for most patients while longer tubing is preferred by patients who feel comfortable keeping the pump in the socks or underneath the pillow while sleeping.

Angle of insertion

Insertion angle 90° is widely used by pump users. From 30° to 45° angles is preferred by dexterous lean or muscular patients and pregnant women.

Selection of infusion sets

The most popular infusion set is a 90°, soft cannula infusion set. Variable angle, soft cannula infusion sets are also available for patients who are lean or lead an active lifestyle. Steel needle infusion sets and 90°, soft cannula infusion sets that combine the infusion set and insertion device into one unit are also available.

Trouble shooting

Adhesive tape allergy

This is extremely rare in Indian scenario and the use of oral antihistaminics for a few days usually suffices. Though there is a possibility of acquiring alternative adhesive materials, in practice, only few patients will require them.

Infusion site infection prophylaxis

The infusion site must be clean and dry before insertion of the cannula. Washing the site with an anti-bacterial soap or solution is sufficient. Changing the infusion set once in every 2-3 days is recommended. In India, most of the pump users retain the same infusion set for 5-7 days due to the high cost of consumables.[13] With this practice, the potency of insulin will be lost; so also are the chances of the site getting infected. Customized advice and recommendations are to be made based on affordability, work pattern and level of education.

Lipohypertrophy

Lipohypertrophy has been described in the FIT India guidelines.[1]

Loss of Insulin potency

If patients use the same reservoir and insulin for more than the recommended 3 days, the potency of insulin may be compromised. If patients fill the reservoir with fresh insulin without changing the infusion set, adequate instructions have to be given by the diabetes care team.

For those subjects working in extremely hot environment, pump may not be a suitable option.

Pump occlusion

If there is any block in the pump, the smart pumps will give out an alarm. The newer cannula rarely kink and block. Among the rapid acting insulins, insulin aspart has the least tendency to produce occlusions. If occlusion persists, the cannula and infusion set have to be changed.[14,15]

CONCLUSION

The FIT India recommendations are an important document for health professionals involved in diabetes care. The addendum (2013) adds to the parent article by describing insulin injection technique related to geriatrics, pregnancy, dermatological disease, surgical disease and pump usage.

This effort is especially timely; these patient populations experience an increase in the prevalence of diabetes, as well as the use of insulin.