Skip to main content
Top
Published in: Diabetes Therapy 11/2020

Open Access 01-11-2020 | Insulins | Original Research

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

Authors: Basel Bari, Marie-Andrée Corbeil, Hena Farooqui, Stuart Menzies, Brian Pflug, Brennan K. Smith, Arthur Vasquez, Lori Berard

Published in: Diabetes Therapy | Issue 11/2020

Login to get access

Abstract

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.
Appendix
Available only for authorised users
Literature
1.
go back to reference Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91:1231–55.CrossRef Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91:1231–55.CrossRef
2.
go back to reference Yuan L, Li F, Jing T, et al. Insulin injection technique is associated with glycemic variability in patients with type 2 diabetes. Diabetes Ther. 2018;9:2347–56.CrossRef Yuan L, Li F, Jing T, et al. Insulin injection technique is associated with glycemic variability in patients with type 2 diabetes. Diabetes Ther. 2018;9:2347–56.CrossRef
3.
go back to reference American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2020. Diabetes Care. 2020;43:S98–110.CrossRef American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2020. Diabetes Care. 2020;43:S98–110.CrossRef
4.
go back to reference Spollett G, Edelman SV, Mehner P, Walter C, Penfornis A. Improvement of insulin injection technique: examination of current issues and recommendations. Diabetes Educ. 2016;42:379–94.CrossRef Spollett G, Edelman SV, Mehner P, Walter C, Penfornis A. Improvement of insulin injection technique: examination of current issues and recommendations. Diabetes Educ. 2016;42:379–94.CrossRef
5.
go back to reference Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide injection technique questionnaire study: population parameters and injection practices. Mayo Clin Proc. 2016;91:1212–23.CrossRef Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide injection technique questionnaire study: population parameters and injection practices. Mayo Clin Proc. 2016;91:1212–23.CrossRef
6.
go back to reference Strauss K, De Gols H, Hannet I, Partanen T-M, Frid A. A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Pract Diabetes Int. 2002;19:71–6.CrossRef Strauss K, De Gols H, Hannet I, Partanen T-M, Frid A. A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Pract Diabetes Int. 2002;19:71–6.CrossRef
7.
go back to reference 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.CrossRef 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.CrossRef
8.
go back to reference Ji J, Lou Q. Insulin pen injection technique survey in patients with type 2 diabetes in mainland China in 2010. Curr Med Res Opin. 2014;30:1087–93.CrossRef Ji J, Lou Q. Insulin pen injection technique survey in patients with type 2 diabetes in mainland China in 2010. Curr Med Res Opin. 2014;30:1087–93.CrossRef
11.
go back to reference Berard L, Cameron B. Injection technique practices in a population of Canadians with diabetes: results from a recent patient/diabetes educator survey. Can J Diabetes. 2015;39:146–51.CrossRef Berard L, Cameron B. Injection technique practices in a population of Canadians with diabetes: results from a recent patient/diabetes educator survey. Can J Diabetes. 2015;39:146–51.CrossRef
12.
go back to reference Karges B, Boehm BO, Karges W. Early hypoglycaemia after accidental intramuscular injection of insulin glargine. Diabet Med. 2005;22:1444–5.CrossRef Karges B, Boehm BO, Karges W. Early hypoglycaemia after accidental intramuscular injection of insulin glargine. Diabet Med. 2005;22:1444–5.CrossRef
13.
go back to reference Thow JC, Johnson AB, Fulcher G, Home PD. Different absorption of isophane (NPH) insulin from subcutaneous and intramuscular sites suggests a need to reassess recommended insulin injection technique. Diabet Med. 1990;7:600–2.CrossRef Thow JC, Johnson AB, Fulcher G, Home PD. Different absorption of isophane (NPH) insulin from subcutaneous and intramuscular sites suggests a need to reassess recommended insulin injection technique. Diabet Med. 1990;7:600–2.CrossRef
14.
go back to reference Gentile S, Strollo F, Ceriello A, et al. Lipodystrophy in insulin-treated subjects and other injection-site skin reactions: are we sure everything is clear? Diabetes Ther. 2016;15:401–9.CrossRef Gentile S, Strollo F, Ceriello A, et al. Lipodystrophy in insulin-treated subjects and other injection-site skin reactions: are we sure everything is clear? Diabetes Ther. 2016;15:401–9.CrossRef
15.
go back to reference 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.CrossRef 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.CrossRef
16.
go back to reference Vora JP, Burch A, Peters HNR, Owens DR. Relationship between absorption of radiolabeled soluble insulin, subcutaneous blood flow, and anthropometry. Diabetes Care. 1992;15:1484–93.CrossRef Vora JP, Burch A, Peters HNR, Owens DR. Relationship between absorption of radiolabeled soluble insulin, subcutaneous blood flow, and anthropometry. Diabetes Care. 1992;15:1484–93.CrossRef
17.
go back to reference Blanco M, Hernández MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013;39:445–53.CrossRef Blanco M, Hernández MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013;39:445–53.CrossRef
18.
go back to reference Ji L, Sun Z, Li Q, et al. Lipohypertrophy in China: prevalence, risk factors, insulin consumption, and clinical impact. Diabetes Technol Ther. 2017;19:61–7.CrossRef Ji L, Sun Z, Li Q, et al. Lipohypertrophy in China: prevalence, risk factors, insulin consumption, and clinical impact. Diabetes Technol Ther. 2017;19:61–7.CrossRef
19.
go back to reference Chowdhury TA. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ. 2003;327:383–4.CrossRef Chowdhury TA. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ. 2003;327:383–4.CrossRef
20.
go back to reference Famulla S, Hovelmann U, Fischer A, et al. Insulin injection into lipohypertrophic tissue: blunted and more variable insulin absorption and action and impaired postprandial glucose control. Diabetes Care. 2016;39:1486–92.CrossRef Famulla S, Hovelmann U, Fischer A, et al. Insulin injection into lipohypertrophic tissue: blunted and more variable insulin absorption and action and impaired postprandial glucose control. Diabetes Care. 2016;39:1486–92.CrossRef
21.
go back to reference Hirsch LJ, Gibney MA, Albanese J, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm × 32G insulin pen needle in adults with diabetes. Curr Med Res Opin. 2010;26:1531–41.CrossRef Hirsch LJ, Gibney MA, Albanese J, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm × 32G insulin pen needle in adults with diabetes. Curr Med Res Opin. 2010;26:1531–41.CrossRef
22.
go back to reference 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.CrossRef 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.CrossRef
23.
go back to reference Laurent A, Mistretta F, Bottigioli D, et al. Echographic measurement of skin thickness in adults by high frequency ultrasound to assess the appropriate microneedle length for intradermal delivery of vaccines. Vaccine. 2007;25:6423–30.CrossRef Laurent A, Mistretta F, Bottigioli D, et al. Echographic measurement of skin thickness in adults by high frequency ultrasound to assess the appropriate microneedle length for intradermal delivery of vaccines. Vaccine. 2007;25:6423–30.CrossRef
24.
go back to reference Bergenstal RM, Strock ES, Peremislov D, Gibney MA, Parvu V, Hirsch LJ. Safety and efficacy of insulin therapy delivered via a 4 mm pen needle in obese patients with diabetes. Mayo Clin Proc. 2015;90:329–38.CrossRef Bergenstal RM, Strock ES, Peremislov D, Gibney MA, Parvu V, Hirsch LJ. Safety and efficacy of insulin therapy delivered via a 4 mm pen needle in obese patients with diabetes. Mayo Clin Proc. 2015;90:329–38.CrossRef
25.
go back to reference Berard L, Cameron B, Woo V. Pen needle preference in a population of Canadians with diabetes: results from a recent patient survey. Can J Diabetes. 2015;39:206–9.CrossRef Berard L, Cameron B, Woo V. Pen needle preference in a population of Canadians with diabetes: results from a recent patient survey. Can J Diabetes. 2015;39:206–9.CrossRef
26.
go back to reference Broadway CA. Commentary: prevention of insulin leakage after subcutaneous injection. Diabetes Educ. 1991;17:90.CrossRef Broadway CA. Commentary: prevention of insulin leakage after subcutaneous injection. Diabetes Educ. 1991;17:90.CrossRef
27.
go back to reference Præstmark KA, Stallknecht B, Jensen ML, Sparre T, Madsen NB, Kildegaard J. Injection technique and pen needle design affect leakage from skin after subcutaneous injections. J Diabetes Sci Technol. 2016;10:914–22.CrossRef Præstmark KA, Stallknecht B, Jensen ML, Sparre T, Madsen NB, Kildegaard J. Injection technique and pen needle design affect leakage from skin after subcutaneous injections. J Diabetes Sci Technol. 2016;10:914–22.CrossRef
29.
go back to reference Rini C, Roberts BC, Morel D, Klug R, Selvage B, Pettis RJ. Evaluating the impact of human factors and pen needle design on insulin pen injection. J Diabetes Sci Technol. 2019;13:533–45.CrossRef Rini C, Roberts BC, Morel D, Klug R, Selvage B, Pettis RJ. Evaluating the impact of human factors and pen needle design on insulin pen injection. J Diabetes Sci Technol. 2019;13:533–45.CrossRef
30.
go back to reference Whooley S, Briskin T, Gibney MA, Blank LR, Berube J, Pflug BK. Evaluating the user performance and experience with a re-engineered 4 mm × 32G pen needle: a randomized trial with similar length/gauge needles. Diabetes Ther. 2019;10:697–712.CrossRef Whooley S, Briskin T, Gibney MA, Blank LR, Berube J, Pflug BK. Evaluating the user performance and experience with a re-engineered 4 mm × 32G pen needle: a randomized trial with similar length/gauge needles. Diabetes Ther. 2019;10:697–712.CrossRef
31.
go back to reference Johansson UB, Amsberg S, Hannerz L, et al. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care. 2005;28:2025–7.CrossRef Johansson UB, Amsberg S, Hannerz L, et al. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care. 2005;28:2025–7.CrossRef
32.
go back to reference Gentile S, Guarino G, Giancaterini A, Guida P, Strollo F, AMD-OSDI Italian Injection Technique Study Group. A suitable palpation technique allows to identify skin lipohypertrophic lesions in insulin-treated people with diabetes. Springerplus. 2016;5:563. Gentile S, Guarino G, Giancaterini A, Guida P, Strollo F, AMD-OSDI Italian Injection Technique Study Group. A suitable palpation technique allows to identify skin lipohypertrophic lesions in insulin-treated people with diabetes. Springerplus. 2016;5:563.
33.
go back to reference Vardar B, Kizilci S. Incidence of lipohypertrophy in diabetic patients and a study of influencing factors. Diabetes Res Clin Pract. 2007;77:231–6.CrossRef Vardar B, Kizilci S. Incidence of lipohypertrophy in diabetic patients and a study of influencing factors. Diabetes Res Clin Pract. 2007;77:231–6.CrossRef
34.
go back to reference Misnikova IV, Gubkina VA, Lakeeva TS, Dreval AV. A randomized controlled trial to assess the impact of proper insulin injection technique training on glycemic control. Diabetes Ther. 2017;8:1309–18.CrossRef Misnikova IV, Gubkina VA, Lakeeva TS, Dreval AV. A randomized controlled trial to assess the impact of proper insulin injection technique training on glycemic control. Diabetes Ther. 2017;8:1309–18.CrossRef
35.
go back to reference Grassi G, Scuntero P, Trepiccioni R, Marubbi F, Strauss K. Optimizing insulin injection technique and its effect on blood glucose control. J Clin Transl Endocrinol. 2014;1:145–50.PubMedPubMedCentral Grassi G, Scuntero P, Trepiccioni R, Marubbi F, Strauss K. Optimizing insulin injection technique and its effect on blood glucose control. J Clin Transl Endocrinol. 2014;1:145–50.PubMedPubMedCentral
36.
go back to reference Nakatani Y, Matsumura M, Monden T, Aso Y, Nakamoto T. Improvement of glycemic control by re-education in insulin injection technique in patients with diabetes mellitus. Adv Ther. 2013;30:897–906.CrossRef Nakatani Y, Matsumura M, Monden T, Aso Y, Nakamoto T. Improvement of glycemic control by re-education in insulin injection technique in patients with diabetes mellitus. Adv Ther. 2013;30:897–906.CrossRef
37.
go back to reference Scain SF, Friedman R, Gross JL. A structured educational program improves metabolic control in patients with type 2 diabetes. Diabetes Educ. 2009;35:603–11.CrossRef Scain SF, Friedman R, Gross JL. A structured educational program improves metabolic control in patients with type 2 diabetes. Diabetes Educ. 2009;35:603–11.CrossRef
38.
go back to reference Szafran O, Kennett SL, Bell NR, Torti JMI. Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team. BMC Fam Pract. 2019;20:44.CrossRef Szafran O, Kennett SL, Bell NR, Torti JMI. Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team. BMC Fam Pract. 2019;20:44.CrossRef
39.
go back to reference Gucciardi E, Xu C, Vitale M, et al. Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes. BMC Fam Pract. 2020;21:48.CrossRef Gucciardi E, Xu C, Vitale M, et al. Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes. BMC Fam Pract. 2020;21:48.CrossRef
40.
go back to reference Alromaihi D, Alamuddin N, George S. Sustainable diabetes care services during COVID-19 pandemic. Diabetes Res Clin Pract. 2020;166:108298. Alromaihi D, Alamuddin N, George S. Sustainable diabetes care services during COVID-19 pandemic. Diabetes Res Clin Pract. 2020;166:108298.
43.
go back to reference Gorska-Ciebiada M, Masierek M, Ciebiada M. Improved insulin injection technique, treatment satisfaction and glycemic control: results from a large cohort education study. J Clin Transl Endocrinol. 2020;19:100217.PubMedPubMedCentral Gorska-Ciebiada M, Masierek M, Ciebiada M. Improved insulin injection technique, treatment satisfaction and glycemic control: results from a large cohort education study. J Clin Transl Endocrinol. 2020;19:100217.PubMedPubMedCentral
44.
go back to reference Iglay K, Hannachi H, Howie PJ, et al. Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Curr Med Res Opin. 2016;32:1243–52.CrossRef Iglay K, Hannachi H, Howie PJ, et al. Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Curr Med Res Opin. 2016;32:1243–52.CrossRef
Metadata
Title
Insulin Injection Practices in a Population of Canadians with Diabetes: An Observational Study
Authors
Basel Bari
Marie-Andrée Corbeil
Hena Farooqui
Stuart Menzies
Brian Pflug
Brennan K. Smith
Arthur Vasquez
Lori Berard
Publication date
01-11-2020
Publisher
Springer Healthcare
Published in
Diabetes Therapy / Issue 11/2020
Print ISSN: 1869-6953
Electronic ISSN: 1869-6961
DOI
https://doi.org/10.1007/s13300-020-00913-y

Other articles of this Issue 11/2020

Diabetes Therapy 11/2020 Go to the issue