Insulin administration: Selecting the appropriate needle and individualizing the injection technique

Expert Opinion on Drug Delivery

Volumn 8, Issue 10, 2011, Pages 1395-1406

  Hansen, Birtha ^a   Matytsina, Irina ^b  

^a AARHUS UNIVERSITY HOSPITAL   (Denmark)

^b NOVO NORDISK A S   (Denmark)

Author keywords

Diabetes; Guidelines; Injection technique; Insulin; Lipohypertrophy

Indexed keywords

INSULIN;

ABDOMEN; BODY MASS; BUTTOCK; CINAHL; DATA BASE; DIABETES MELLITUS; GLYCEMIC CONTROL; HUMAN; INJECTION SITE; INSULIN TREATMENT; MEDLINE; METABOLIC REGULATION; NEEDLE; OBESITY; PATIENT SATISFACTION; PEDIATRICS; REVIEW; SUBCUTANEOUS TISSUE; THIGH;

DIABETES MELLITUS; EQUIPMENT DESIGN; HUMANS; HYPOGLYCEMIC AGENTS; INJECTIONS; INSULIN; NEEDLES;

EID: 80053070124     PISSN: 17425247     EISSN: 17447593     Source Type: Journal    
DOI: 10.1517/17425247.2011.614229     Document Type: Review

References (96)

1. American Diabetes Association. Standards of medical care in diabetes-2011. Diabetes Care 2011;34(Suppl 1):S11-61
2. Nathan DM, Buse JB, Davidson MB, et al. American Diabetes Association, European Association for Study of Diabetes. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32:193-203
3. Kilpatrick ES, Das AK, Ørskov C, Berntorp C. Good glycaemic control: an international perspective on bridging the gap between theory and practice in type 2 diabetes. Curr Med Res Opin 2008;8:2651-61
4. Dale J, Martin S, Gadsby R. Insulin initiation in primary care for patients with type 2 diabetes: 3-Year follow-up study. Prim Care Diabetes 2010;4:85-9
5. Ford ES, Li C, Little RR, Mokdad AH. Trends in A1C concentrations among U. S. adults with diagnosed diabetes from 1999 to 2004. Diabetes Care 2008;31:102-4
6. Seyoum B, Abdulkadir J. Systematic inspection of insulin injection sites for local complications related to incorrect injection technique. Trop Doct 1996;26:159-61 (Pubitemid 26362647)
7. Shin H, Kim MJ. Subcutaneous tissue thickness in children with type 1 diabetes. J Adv Nurs 2006;54:29-34 (Pubitemid 43433750)
8. Strauss K, De Gols H, Hannet I, et al. A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Pract Diabetes Int 2002;19:71-6
9. American Diabetes Association. Insulin administration. Diabetes Care 2004;27(S1):S106-9
10. Stacciarini TS, Pace AE, Haas VJ. Insulin self-administration technique with disposable syringe among patients with diabetes mellitus followed by the family health strategy. Rev Lat Am Enfermagem 2009;17:474-80
11. De Coninck C, Frid A, Gaspar R, et al. Results and analysis of the 2008-2009 insulin injection technique questionnaire survey. J Diabetes 2010;2:168-79
12. Rubin RR, Peyrot M, Kruger DF, Travis LB. Barriers to insulin injection therapy: patient and health care provider perspectives. Diabetes Educ 2009;35:1014-22
13. Karges B, Muche R, Moritz M, et al. Low discomfort and pain associated with intensified insulin therapy in children and adolescents. Diabetes Res Clin Pract 2008;80:96-101
14. Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002;25:1159-71 (Pubitemid 41071167)
15. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561-87 (Pubitemid 32198430)
16. Yong A, Power E, Gill G. Improving glycaemic control of insulin-treated diabetic patients-a structured audit of specialist nurse intervention. J Clin Nurs 2002;11:773-6 (Pubitemid 41697940)
17. Berikai P, Meyer PM, Kazlauskaite R, et al. Gain in patients' knowledge of diabetes management targets is associated with better glycemic control. Diabetes Care 2007;30:1587-9 (Pubitemid 46871178)
18. Annersten M, Willman A. Performing subcutaneous injections: a literature review. Worldviews Evid Based Nurs 2005;2:122-30 (Pubitemid 41702683)
19. Hansen B, Kirketerp G, Ehlers G, et al. for the Danish Nurses Association. Evidence-based clinical guidelines for injection of insulin for adults with diabetes mellitus. 2nd edition. Danish Nurses Organization; Arhus: 2007
20. Registered Nurses Association of Ontario. Best practice guideline for the subcutaneous administration of insulin in adults with type 2 diabetes. Registered Nurses Association of Ontario; Toronto: 2004
21. Frid A, Hirsch L, Gaspar R, et al. Scientific Advisory Board for the Third Injection Technique Workshop. New injection recommendations for patients with diabetes. Diabetes Metab 2010;36(Suppl 1):S3-18
22. Iwanaga M, Kamoi K. Patient perceptions of injection pain and anxiety: a comparison of NovoFine 32-gauge tip 6mm and Micro Fine Plus 31-gauge 5mm needles. Diabetes Technol Ther 2009;11:81-6
23. Miyakoshi M, Kamoi K, Iwanaga M, et al. Comparison of patient's preference, pain perception, and usability between Micro Fine Plus 31-gauge needle and Microtapered NanoPass 33-gauge needle for insulin therapy. J Diabetes Sci Technol 2007;1:718-24
24. Prettyman J. Subcutaneous or intramuscular? Confronting a parenteral administration dilemma. Medsurg Nurs 2005;14:93-8.quiz 99
25. McKay M, Compion G, Lytzen L. A comparison of insulin injection needles on patients' perceptions of pain, handling, and acceptability: a randomized, open-label, crossover study in subjects with diabetes. Diabetes Technol Ther 2009;11:195-201
26. Brunton SA, Davis SN, Renda SM. Overcoming psychological barriers to insulin use in type 2 diabetes. Clin Cornerstone 2006;8(Suppl 2):S19-26 (Pubitemid 44283560)
27. Davis SN, Renda SM. Psychological insulin resistance: overcoming barriers to starting insulin therapy. Diabetes Educ 2006;32(Suppl 4):146S-52S
28. Egekvist H, Bjerring P, Arendt-Nielsen L. Pain and mechanical injury of human skin following needle insertions. Eur J Pain 1999;3:41-9 (Pubitemid 29166621)
29. Fu AZ, Qiu Y, Radican L. Impact of fear of insulin or fear of injection on treatment outcomes of patients with diabetes. Curr Med Res Opin 2009;25:1413-20
30. Chantelau E, Lee DM, Hemmann DM, et al. What makes insulin injections painful? BMJ 1991;303:26-7
31. Hirsch LJ, Gibney MA, Albanese J, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm X 32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41
32. Nir Y, Paz A, Sabo E, Potasman I. Fear of injections in young adults: prevalence and associations. Am J Trop Med Hyg 2006;68:341-4
33. King L. Subcutaneous insulin injection technique. Nurs Stand 2003;17:45-52
34. Arendt-Nielsen L, Egekvist H, Bjerring P. Pain following controlled cutaneous insertion of needles with different diameters. Somatosens Mot Res 2006;23:37-43 (Pubitemid 44114991)
35. Schwartz S, Hassman D, Shelmet J, et al. A multicenter, open-label, randomized, two-period crossover trial comparing glycaemic control, satisfaction, and preference achieved with a 31 gauge X 6 mm needle versus a 29 gauge X 12.7 mm needle in obese patients with diabetes mellitus. Clin Ther 2004;26:1663-78 (Pubitemid 39643027)
36. Adams D, Elliott TS. Impact of safety needle devices on occupationally acquired needlestick injuries: a four-year prospective study. J Hosp Infect 2006;64:50-5 (Pubitemid 44161379)
37. Lytzen L, Ostfeldt L. Comparative assessment of NovoTwist™, a novel insulin pen needle system. Diabetes 2009;58(Suppl 1):A509
38. Lautier O, Mosnier-Pudar M, Durain D, et al. Risk of needlestick injuries among nurses using novofine® autocover® safety needles and nurses' satisfaction with the needles: the NOVAC study. Insulin 2008;3:232-7
39. Sommavilla B, Jørgensen C, Jensen KH. Safety, simplicity and convenience of a modified prefilled insulin pen. Expert Opin Pharmacother 2008;9:2223-32
40. Hansen B, Lilleøre SK, Ter-Borch G. Needle with a novel attachment versus conventional screw-thread needles: a preference and usability test among adults with diabetes and impaired manual dexterity. Diabetes Technol Ther 2011;13:579-85
41. Molin A, Larsen C, Lawton SA. Reduced flow resistance in insulin pen needles designed with thin wall technology. Diabetes 2002;51(Suppl 2):A475
42. Siegmund T, Blankenfeld H, Schumm-Draeger PM. Comparison of usability and patient preference for insulin pen needles produced with different production techniques: "thin-wall" needles compared to "regular-wall" needles: an open-label study. Diabetes Technol Ther 2009;11:523-8
43. Hofman PL, Behrensdorf Derraik JG, Pinto TE, et al. Defining the ideal injection techniques when using 5-mm needles in children and adults. Diabetes Care 2010;33:1940-4
44. Kreugel G, Beijer HJM, Kerstens MN, et al. Influence of needle size for subcutaneous insulin administration on metabolic control and patient acceptance. Eur Diabetes Nurs 2007;4:51-5
45. Frid A, Gunnarsson R, Guntner P, Linde B. Effects of accidental intramuscular injection on insulin absorption in IDDM. Diabetes Care 1988;11:41-5
46. Vaag A, Handberg AA, Laritzen M, et al. Variation in absorption of NPH insulin due to intramuscular injection. Diabetes Care 1990;13:74-6 (Pubitemid 20024733)
47. Frid A, Ostman J, Linde B. Hypoglycemia risk during exercise after intramuscular injection of insulin in thigh in IDDM. Diabetes Care 1990;13:473-7 (Pubitemid 20145949)
48. Pettis RJ, Ginsberg B, Hirsch L, et al. Intradermal microneedle delivery of insulin lispro achieves faster insulin absorption and insulin action than subcutaneous injection. Diabetes Technol Ther 2011;13:435-42
49. Pettis RJ, Hirsch L, Kapitza C, et al. Microneedle-based intradermal versus subcutaneous administration of regular human insulin or insulin lispro: pharmacokinetics and postprandial glycemic excursions in patients with type 1 diabetes. Diabetes Technol Ther 2011;13:443-50
50. Harvey AJ, Kaestner SA, Sutter DE, et al. Microneedle-based intradermal delivery enables rapid lymphatic uptake and distribution of protein drugs. Pharm Res 2011;28:107-16
51. International Diabetes Federation Clinical Guidelines Task Force. Global guideline for type 2 diabetes. International Diabetes Federation; Brussels: 2005
52. Bangstad H-J, Danne T, Deeb LC, et al. ISPAD Clinical practice consensus guidelines 2009 compendium: insulin treatment in children and adolescents with diabetes. Pediatr Diabetes 2009;10(Suppl 12):82-99
53. Gibney MA, Arce CH, Byron KJ, Hirsch LJ. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendations. Curr Med Res Opin 2010;26:1519-30
54. Seidenari S, Giusti G, Bertoni L, et al. Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound. Dermatology 2000;201:218-22
55. Thow JC, Coulthard A, Home PD. Insulin injection site tissue depths and localization of a simulated insulin bolus using a novel air contrast ultrasonographic technique in insulin treated diabetic subjects. Diabet Med 1992;9:915-20
56. Tubiana-Rufi N, Belarbi N, Du Pasquier-Fediaevsky L, et al. Short needles (8 mm) reduce the risk of intramuscular injections in children with type 1 diabetes. Diabetes Care 1999;22:1621-5 (Pubitemid 29458383)
57. Polak M, Beregszaszi M, Belarbi N, et al. Subcutaneous or intramuscular injections of insulin in children. Are we injecting where we think we are? Diabetes Care 1996;19:1434-6 (Pubitemid 26418630)
58. Frid A, Linden B. Where do lean diabetics inject their insulin. A study using computed tomography. BMJ 1986;292:1638 (Pubitemid 16097873)
59. Karges B, Boehm BO, Karges W. Early hypoglycaemia after accidental intramuscular injection of insulin glargine. Diabet Med 2005;22:1444-5 (Pubitemid 41391325)
60. Hofman PL, Lawton SA, Peart JM, et al. An angled insertion technique using 6-mm needles markedly reduces the risk of intramuscular injections in children and adolescents. Diabet Med 2007;24:1400-5 (Pubitemid 350179428)
61. Strauss K, Hannet I. Gonigle J Mc, et al. Ultra-short (5mm) insulin needles; trial results and clinical recommendations. Pract Diabetes Int 1999;16:218-12
62. Clinical guideline 15 type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Update, June 2009. London: National Institute for Health and Clinical Excellence (NICE). Available from: www.nice.org.uk/nicemedia/pdf/CG015NICEGuidelineUpdate.pdf [Last accessed 23 March 2010]
63. Birkebaek NH, Solvig J, Hansen B, et al. A 4-mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care 2008;31:e65
64. Type 2 Diabetes: National clinical guidelines for management in primary and secondary care (update). National Collaborating Centre for Chronic Conditions. London: Royal College of Physicians, 2008. Available from: www. nice.org.uk/nicemedia/pdf/CG66FullGuideline0509.pdf [Last accessed 23 March 2010]
65. Wittmann A, Kover J, Kralj N, et al. Insulin leakage value in relation to pen needle length and administered dose after subcutaneous injection. Diabetes Technol Ther 2010;12:587-90
66. Annersten M, Frid A. Insulin pens dribble from the tip of the needle after injection. Pract Diabetes Int 2000;17:109-11
67. Kreugel G, Keers JC, Kerstens MN, Wolffenbuttel BH. Randomized trial on the influence of the length of two insulin pen needles on glycemic control and patient preference in obese patients with diabetes. Diabetes Technol Ther 2011;13:737-41
68. Puder JJ, Atar M, Muller B, et al. Using insulin pen needles up to five times does not affect needle tip shape nor increase pain intensity. Diabetes Res Clin Pract 2005;67:119-23 (Pubitemid 40093021)
69. NovoRapid [summary of product characteristics]. Bagsværd: Novo Nordisk A/S, 2010. Available from: www.ema. europa.eu/docs/en-GB/document- library/EPAR-Product-Information/human/000258/WC500030372.pdf [Last accessed 16 February 2011]
70. Humalog [summary of product characteristics]. Houton: Eli Lilly Nederland B.V. 2010. Available from: www.ema.europa.eu/docs/en-GB/document-library/EPAR- Product-Information/human/000088/WC500050332.pdf [Last accessed 16 February 2011]
71. Apidra [summary of product characteristics]. Frankfurt: Sanofi-Aventis Deutschland GmbH. 2010. Available from: www.ema.europa.eu/docs/en-GB/document- library/EPAR-Product-Information/human/000557/WC500025250.pdf [Last accessed 16 February 2011]
72. Levemir [summary of product characteristics]. Bagsværd: Novo Nordisk A/S, 2010. Available from: www.ema. europa.eu/docs/en-GB/document- library/EPAR-Product-Information/human/000528/WC500036662.pdf [Last accessed 16 February 2011]
73. Lantus [summary of product characteristics]. Frankfurt am Main: Sanofi-Aventis Deutschland GmbH. 2010. Available from: www.ema.europa. eu/docs/en-GB/document-library/EPAR-Product-Information/human/000284/ WC500036082.pdf [Last accessed 16 February 2011]
74. Bantle J, Neal L, Frankamp L. Effects of the anatomical region used for insulin injections on glycaemia in type I diabetes subjects. Diabetes Care 1993;16:1592-7 (Pubitemid 23353736)
75. McNally P, Jowet N, Kurinczuk J, et al. Lipohypertrophy and lipoatrophy complicating treatment with highly purified bovine and porcine insulin. Postgrad Med 1988;64:850-3 (Pubitemid 19011081)
76. Teft G. Lipohypertrophy: patient awareness and implications for practice. J Diabetes Nurs 2002;6:20-3
77. Hambridge K. The management of lipohypertrophy in diabetes care. Br J Nurs 2007;16:520-4
78. Vardar B, KIzIlcI S. Incidence of lipohypertrophy in diabetic patients and a study of influencing factors. Diabetes Res Clin Pract 2007;77:231-6 (Pubitemid 46670424)
79. Saez-de Ibarra L, Gallego F. Factors related to lipohypertrophy in insulin-treated diabetic patients; role of educational intervention. Pract Diabetes Int 1998;15:9-11 (Pubitemid 28115829)
80. Partanen T, Rissanen A. Insulin injection practices, Practical Diabetes International. 2000;17:252-4 (Pubitemid 32094251)
81. Chowdhury T, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ 2003;327:383-8
82. Zehrer C, Hansen R, Bantle J. Reducing blood glucose variability by use of abdominal insulin injection sites. Diabetes Educ 1990;16:474-7
83. Heinemann L. Variability of insulin absorption and insulin action. Diabetes Technol Ther 2002; 4: 673-82 (Pubitemid 35283332)
84. Gin H, Hanaire-Broutin H. Reproducibility and variability in the action of injected insulin. Diabetes Metab 2005;31:7-13 (Pubitemid 40327587)
85. Lindholm A, Jacobsen LV. Pharmacokinetics and pharmacodynamics of insulin aspart. Clin Pharmacokinet 2001;40:641-59
86. Havelund S, Plum A, Ribel U, et al. The mechanism of protraction of insulin detemir, a long-acting, acylated analog of human insulin. Pharm Res 2004;21:1498-504 (Pubitemid 39149667)
87. Helms KL, Kelley KW. Insulin Glulisine: an evaluation of its pharmacodynamic properties and clinical application. Ann Pharmacother 2009;43:658-68
88. Garnock-Jones KP, Plosker GL. Insulin Glulisine: A review of its use in the management of diabetes mellitus. Drugs 2009;69:1035-57
89. Brange J, Vølund A. Insulin analogs with improved pharmacokinetic profiles. Adv Drug Deliv Rev 1999;35:307-35 (Pubitemid 29073621)
90. Siebenhofer A, Plank J, Berghold A, et al. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database of Syst Rev 2006;CD003287
91. Ross SA, Jamal R, Leiter RA, et al. Evalution of 8 mm insulin pen needles in people with type 1 and type 2 diabetes. Pract Diabetes Int 1999;16:145-8 (Pubitemid 29410623)
92. Smith CP, Sargent MA, Wilson BPM, Price DA. Subcutaneous or intramuscular insulin injections. Arch Dis Child 1991;66:879-82
93. Lawton SA. A practical guide to insulin injection. A resource for diabetes educators. Novo Nordisk A/S; Bagsværd: 2000
94. Byetta® Pen User Manual. Eli Lilly and Co., 2007
95. FlexPen® User Guide. Available from: http://www.novonordisk.com/ images/diabetes/pdf/flexpen-user-manual.pdf [Last accessed 15 June 2011]
96. SoloSTAR® User Guide. Available from: http://www.lantus.com/docs/ consumer/pdf/Lantus-SoloSTAR-Quick-Reference-Guide-Tearpad.pdf [Last accessed 15 June 2011]