TABLE 1.

Top 10 IT Recommendations

1. Have patients demonstrate their IT, either by performing an actual injection or by injecting into a pad or foam pillow. Use this as a teaching occasion, praising what they do correctly and correcting any improper practices.

2. Injections should only be given into clean, healthy sites using clean hands. Disinfecting the skin is generally not required.

3. Injections must be given subcutaneously, not intramuscularly. The 4-mm pen needle has the lowest risk of IM injection and allows wider zones for rotation.

4. Needles that are 12.7 mm in length are not recommended for any patients, and patients who are using 8-mm needles should be switched to shorter lengths.

5. The 4-mm needle is preferred for all injectors regardless of age, sex, ethnicity, or BMI. It should be inserted perpendicular to the skin (90° to skin surface)—not at an angle—regardless of whether a skinfold is raised.

6. Very young children (≤6 years of age) and very thin adults (BMI <19 kg/m2) should always inject with the 4-mm needle into a lifted skinfold. Other children, adolescents, and adults may inject without a skinfold.

7. Inspect patient injection sites at least annually, both visually and by palpation using gel to aid in detection of LH. Make patients aware of the presence of any LH, and instruct them not to inject into it. Use the LH lesion to teach them what to feel and look for and engage them in surveying their injection sites.

8. If LH is found, switch injections to normal tissue while decreasing the dose of insulin. Reductions often exceed 20% of the original dose. Monitor SMBG results closely.

9. Rotate injections systematically to avoid LH, injecting at least 1 cm (approximate width of an adult finger) from previous injections.

10. If possible, patients should avoid reusing needles, which are sterile, one-use devices. Excessive reuse (more than five times) has been associated with LH.