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Open Access 01-08-2018 | Original Research

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

Authors: Selcuk Dagdelen, Oguzhan Deyneli, Nermin Olgun, Zeynep Osar Siva, Mehmet Sargin, Sükrü Hatun, Mustafa Kulaksizoglu, Ahmet Kaya, Cansu Aslan Gürlek, Laurence J. Hirsch, Kenneth W. Strauss, the ITQ Turkish Study Group

Published in: Diabetes Therapy | Issue 4/2018

Abstract

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.

International Diabetes Federation (IDF). IDF diabetes atlas—8th edn. http://www.diabetesatlas.org/resources/2017-atlas.html. Last accessed 12 May 2018.

Satman I, Omer B, Tutuncu Y, et al. Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. Eur J Epidemiol. 2013;28(2):169–80. https://doi.org/10.1007/s10654-013-9771-5.CrossRefPubMedPubMedCentral

Frid AH, Kreugel G, Grassi G. Worldwide Injection Technique Questionnaire study: population parameters and injection practices. Mayo Clin Proc 2016;91(9):1212–23. Open Access at: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30322-6/fulltext. Accessed 12 May 2018.CrossRefPubMed

Frid AH, Kreugel G, Grassi G. Worldwide Injection Technique Questionnaire study: injecting complications and role of the professional. Mayo Clin Proc 2016;91(9):1224–30. Open Access at: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30326-3/fulltext. Accessed 12 May 2018.CrossRefPubMed

Frid AH, Kreugel G, Grassi G. New insulin delivery recommendations. Mayo Clin Proc 2016;91(9):1231–55. Open Access at: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30321-4/fulltext. Accessed 12 May 2018.CrossRefPubMed

Drake MT, Smith SA. Optimizing insulin delivery in patients with diabetes mellitus: still room for improvement. Mayo Clin Proc 2016;91(Issue 9):155–1157. (Accompanying editorial to the three preceding Mayo Clinic Proceedings papers). Open Access at: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30410-4/fulltext. Last accessed 12 May 2018.

Saglık Çalısanları Için Insülin Enjeksiyon Teknikleri ve Tedavileri Kılavuzu Halk Saglıgı Genel Müdürlügü, Yayın No: 1093, Ankara ve Yayın Tarihi: 2018.

Kalra S, Mithal A, Sahay R, et al. Indian Injection Technique Study: population characteristics and injection practices. Diabetes Ther. 2017;8(3):637–57. https://doi.org/10.1007/s13300-017-0243-x.CrossRefPubMedPubMedCentral

yyTableau Public Adam Young’s Profile website. ITQ survey data. http://tabsoft.co/23V6ofi. Last accessed 12 May 2018.

10.

Bantle JP, Neal L, Frankamp LM. Effects of the anatomical region used for insulin injections on glycaemia in type 1 diabetes subjects. Diabetes Care. 1993;16:1592–7.CrossRefPubMed

11.

Frid A, Lindén B. Intraregional differences in the absorption of unmodified insulin from the abdominal wall. Diabet Med. 1992;9:236–9.CrossRefPubMed

12.

Koivisto VA, Felig P. Alterations in insulin absorption and in blood glucose control associated with varying insulin injection sites in diabetic patients. Ann Intern Med. 1980;92:59–61.CrossRefPubMed

13.

Annersten M, Willman A. Performing subcutaneous injections: a literature review. Worldviews Evid Based Nurs. 2005;2:122–30.CrossRefPubMed

14.

Vidal M, Colungo C, Jansà M. Actualización sobre técnicas y sistemas de administración de la insulina (I) [Update on insulin administration techniques and devices (I)]. Av Diabetol. 2008;24:175–90.

15.

Gagliardino JJ, Atanasov PK, Chan JC, et al. Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the International Diabetes Management Practice Study (IDMPS). BMJ Open Diabetes Res Care. 2017;5(1):e000297. https://doi.org/10.1136/bmjdrc-2016-000297.CrossRefPubMedPubMedCentral

16.

Damci T, Emral R, Svendsen AL, Balkir T, Vora J. Lower risk of hypoglycaemia and greater odds for weight loss with initiation of insulin detemir compared with insulin glargine in Turkish patients with type 2 diabetes mellitus: local results of a multinational observational study. BMC Endocr Disord. 2014;14:61. https://doi.org/10.1186/1472-6823-14-61.CrossRefPubMedPubMedCentral

17.

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.CrossRefPubMed

18.

Strollo F, Gentile S. Comment on the New Indian Injection Technique Recommendations: critical appraisal of the real-world implementation of the current guidelines. Diabetes Ther. 2017;8(3):507–11. https://doi.org/10.1007/s13300-017-0262-7.CrossRefPubMedPubMedCentral

19.

Jain SM, Pandey K, Lahoti A, Rao PK. Evaluation of skin and subcutaneous tissue thickness at insulin injection sites in Indian, insulin naïve, type-2 diabetic adult population. Indian J Endocrinol Metab. 2013;17(5):864–70.CrossRefPubMedPubMedCentral

20.

Hirsch L, Byron K, Gibney M. Intramuscular risk at insulin injection sites-measurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous insulin therapy. Diabetes Technol Ther. 2014;16(12):867–73.CrossRefPubMed

21.

Lo Presti D, Ingegnosi C, Strauss K. Skin and subcutaneous thickness at injecting sites in children with diabetes: ultrasound findings and recommendations for giving injection. Pediatr Diabetes. 2012;13(7):525–33.CrossRefPubMed

22.

Bergenstal RM, Strock ES, Peremislov D. Safety and efficacy of insulin therapy delivered via a 4 mm pen needle in obese patients with diabetes. Mayo Clin Proc. 2015;90(3):329–38.CrossRefPubMed

23.

Birkebaek N, Solvig J, Hansen B, Jorgensen C, Smedegaard J, Christiansen J. 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;22:e65.CrossRef

24.

Jamal R, Ross SA, Parkes JL, Pardo S, Ginsberg BH. Role of injection technique in use of insulin pens: prospective evaluation of a 31-gauge, 8 mm insulin pen needle. Endocr Pract. 1999;5:245–50.CrossRefPubMed

25.

Kreugel G, Keers JC, Jongbloed A, Verweij-Gjaltema AH, Wolffenbuttel BHR. The influence of needle length on glycemic control and patient preference in obese diabetic patients. Diabetes. 2009;58:A117.

26.

Schwartz S, Hassman D, Shelmet J, et al. A multicenter, open-label, randomized, two-period crossover trial comparing glycemic control, satisfaction, and preference achieved with a 31 gauge x 6 mm needle versus a 29 gauge × 12.7 mm needle in obese patients with diabetes mellitus. Clin Ther. 2004;26:1663–78.CrossRefPubMed

27.

Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size for SC insulin administration on metabolic control and patient acceptance. Eur Diab Nurs. 2007;4:1–5.

28.

Van Doorn LG, Alberda A, Lytzen L. Insulin leakage and pain perception with NovoFine 6 mm and NovoFine 12 mm needle lengths in patients with type 1 or type 2 diabetes. Diabet Med. 1998;1:S50.

29.

Miwa T, Itoh R, Kobayashi T, et al. Comparison of the effects of a new 32-gauge × 4-mm pen needle and a 32-gauge × 6-mm pen needle on glycemic control, safety, and patient ratings in Japanese adults with diabetes. Diabetes Technol Ther. 2012;14(12):1084–90.CrossRefPubMed

30.

Nagai Y, Ohshige T, Arai K, Kobayashi H, Sada Y, Ohmori S. Comparison between shorter straight and thinner microtapered insulin injection needles. Diab Tech Ther. 2013;15(7):550–5.CrossRef

31.

Hirose T, Ogihara T, Tozaka S, Kanderian S, Watada H. Identification and comparison of insulin pharmacokinetics injected with a new 4-mm needle vs 6–and 8-mm needles accounting for endogenous insulin and C-peptide secretion kinetics in non-diabetic adult males. J Diabetes Investig. 2013;4(3):287–96.CrossRefPubMedPubMedCentral

32.

de la Peña A, Yeo KP, Linnebjerg H, et al. Subcutaneous injection depth does not affect the pharmacokinetics or glucodynamics of insulin lispro in normal weight or healthy obese subjects. J Diabetes Sci Technol. 2015;9:1–7.

33.

Blanco M, Hernández MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013;39(5):445–53.CrossRefPubMed

34.

Hirsch L, Ji L, Sun Z, Li Q, et al. Lipohypertrophy—prevalence, risk factors and clinical characteristics of insulin-requiring patients in China. DTT. 2015;17[Suppl 1]:A57–8.

35.

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(3):168–79.CrossRefPubMed

36.

Dagdelen S, Deyneli O, Olgun N, et al. Turkish insulin injection technique study: complications experienced by Turkish patients with diabetes who inject insulin, education they received and the role of health care professional as assessed by survey questionnaire. Diabetes Ther. 2018

37.

Kalra S, Mithal A, Sahay R, et al. Indian injection technique study: population characteristics and injection practices. Diabetes Ther. 2017;8(3):637–57. https://doi.org/10.1007/s13300-017-0243-x.CrossRefPubMedPubMedCentral

38.

Kalra S, Mithal A, Sahay R, et al. Indian injection technique study: injecting complications, education, and the health care professional. Diabetes Ther. 2017;8(3):659–72. https://doi.org/10.1007/s13300-017-0244-9.CrossRefPubMedPubMedCentral

39.

Title: 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
Authors: Selcuk Dagdelen
Oguzhan Deyneli
Nermin Olgun
Zeynep Osar Siva
Mehmet Sargin
Sükrü Hatun
Mustafa Kulaksizoglu
Ahmet Kaya
Cansu Aslan Gürlek
Laurence J. Hirsch
Kenneth W. Strauss
the ITQ Turkish Study Group
Publication date: 01-08-2018
Publisher: Springer Healthcare
Published in: Diabetes Therapy / Issue 4/2018
Print ISSN: 1869-6953
Electronic ISSN: 1869-6961
DOI: https://doi.org/10.1007/s13300-018-0464-7

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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

Abstract

Introduction

Methods

Results

Conclusion

Funding

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Abstract

Introduction

Methods

Results

Conclusion

Funding

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