Addendum 1: Forum for Injection Technique and Therapy Expert Recommendations, India

With the emerging complexities in chronic diseases and people's lifestyles, healthcare professionals (HCPs) need to update their methods to manage and educate patients with chronic lifestyle disorders, particularly diabetes. The insulin injection technique (IIT), along with various parameters, must also be updated with newer methods. Forum for Injection Technique and Therapy Expert Recommendations (FITTER), India, has updated its recommendations to cover newer ways of detecting hypoglycaemia and lipohypertrophy, preventing needlestick injuries (NSIs), discouraging the reuse of insulin needles and encouraging good disposal. FITTER, India, is also introducing recommendations to calculate insulin bolus dose. These updated recommendations will help HCPs better manage patients with diabetes and achieve improved outcomes.

Effectiveness of clinical pharmacist-led smartphone application on medication adherence, insulin injection technique and glycemic control for women with gestational diabetes receiving multiple daily insulin injection: A randomized clinical trial

AIM

To investigate the efficacy of a clinical pharmacist-led smartphone application (app) on medication adherence, insulin injection technique (IIT) and diabetes-related outcomes among women with gestational diabetes mellitus (GDM) receiving insulin therapy.

METHOD

In all, 124 women were randomly (1:1 ratio) assigned to receive app intervention plus usual care (intervention) or usual care (control), and were followed up till 12 weeks postpartum. Interventions centralized on medication adherence and IIT. Primary outcome was medication adherence assessed by the 5-item Medication Adherence Report Scale. Secondary outcomes included IIT, insulin requirement, prepartal and puerperal glycemic control, hypoglycemia, and pregnancy and neonatal outcomes.

RESULTS

A total of 119 patients completed the follow-up evaluation (58 intervention, 61 control). Significant more women with high medication adherence in the intervention group was observed (69.0% vs. 34.4%, p = 0.000). The other notable benefits (all p < 0.05) included patient percentage with appropriate IIT, lesser preprandial insulin dose, patient proportion with both qualified prepartal FPG and 2 hPG, and puerperal FPG or HbA1c, fewer hypoglycemia, and lower neonatal intensive care unit (NICU) admission rate. Cesarean delivery rate was higher among intervention cases (p < 0.05). Qualified prepartal glycemic control was related to high medication adherence and proper IIT. NICU admission was associated with complicated with gestational hypertension, deficient medication adherence and premature rupture of fetal membrane.

CONCLUSION

Combined with usual care, clinical pharmacist-led smartphone app might be a valid tool for GDM management.

Impact of pharmacist insulin injection re-education on glycemic control among type II diabetic patients in primary health clinics

Background

Insulin injection technique re-education and diabetes knowledge empowerment has led to improved glycemic control.

Objectives

To evaluate the impact of pharmacist's monthly re-education on insulin injection technique (IT), lipohypertrophy, patients' perception on insulin therapy and its effect on glycaemic control.

Methods

This randomized controlled, multi-centered study was conducted among type 2 diabetics from 15 government health clinics. 160 diabetics with baseline HbA1_C ≥ 8% and unsatisfactory IT technique were randomized into control or intervention group. Control group received standard pharmacist counselling during initiation and at 4th month. Intervention group received monthly counselling and IT re-education for 4 months. Assessment of diabetes, IT knowledge, adherence and perception towards diabetes were conducted using validated study tools Insulin Treatment Appraisal Scale (ITAS) and Medication Compliance Questionnaire (MCQ)).

Results

139 patients completed the study; control group (69), intervention group (70). In control group, all outcomes shown improvement except for patient's perception. Mean HbA1_C decreased 0.79% ± 0.24 (p = 0.001). In intervention group, all outcomes improved significantly. HbA1c reduces significantly by 1.19% ± 0.10 (p < 0.001). Monthly re-education improved patient's perception towards insulin therapy (ITAS score reduced 1.44 ± 2.36; p = 0.021). Between groups, interventional arm shown significantly better improvement in all outcomes. Improvement was shown in IT technique (+2.02 score; p < 0.001), medication adherence (+1.48 score; p < 0.001) and ITAS (-1.99 score; p = 0.037). Mean HbA1_C reduced an additional of 0.63% (p = 0.008) compared to control arm.

Conclusion

Re-education is more effective in increasing adherence, reducing lipohypertrophy, improving injection technique and patient's perception on insulin therapy, thereby providing better glycaemic control.

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

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.

Improved insulin injection technique, treatment satisfaction and glycemic control: Results from a large cohort education study

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The efficacy of insulin therapy in diabetes depends on proper injection technique.

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Professional education can results in higher patients’ satisfaction.

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Proper insulin injection is important to good glycemic control.

Objective

The aim of this study was to elucidate injection techniques, treatment satisfaction and glycemic control after education among patients with type 2 diabetes.

Methods

4513 insulin-treated diabetic patients enrolled in the observational study EGIDA II (Education and GensuPen In Diabetology II) filled out the questionnaire which focused on key insulin injection parameters, pain sensation scale and satisfaction of the treatment form before (visit 1) and after 3 months treatment with insulin injection (visit 2). The education was performed by trained healthcare professionals. To assess the utility and comfort during using new automatic injection system (GensuPen) we separated 2 groups: A – treated with GensuPen and B – treated with other pens.

Results

The education resulted in increased number of patients who properly remix cloudy insulin; inject insulin into skin; change every time the injection site; use the pen needle only once; prepare a pen for injection and store insulin. We noticed significant decrease in BMI and sensation of pain in both groups. Our study revealed that patients’ satisfaction with the treatment increased with each of the 5 items (type of the treatment, mood, physical activity, vital energy, a sense of control over the disease) using a 5-point scale, with greater increase in group A. The utility and comfort (weight, thickness, easiness in remove pen cap, cleaning, twisting, keeping in hand the pen, dial the dose, readable signaling of injected dose) during using the GensuPen significantly increased in group A. Finally the mean glucose level in self-control diary was significantly lower after 3 months of the treatment in both groups, however the difference between visit 1 and 2 was greater in group A.

Conclusion

The study showed that proper selection of pen and professional education can result in the improvement of insulin injection technique, higher patients’ satisfaction and better glycemic control.

Clinical Implications of Lipohypertrophy Among People with Type 1 Diabetes in India

BACKGROUND

Lipohypertrophy (LH) at insulin injection sites is a common but preventable complication in type 1 diabetes mellitus (T1DM). We evaluated the prevalence, contributing risk factors, and consequences of LH, specifically the glycemic variability (GV) among T1DM patients.

METHODS

This is a cross-sectional study conducted at a tertiary care center in India, wherein 139 subjects with T1DM were randomly selected and evaluated for the presence of LH through visual and palpation examinations. Demography, anthropometry, and injecting practices were evaluated using a validated questionnaire and their effect on LH was determined. Subsequently, the effect of LH on GV and unexplained hypoglycemia (UH) was studied. Mean glucose, mean amplitude of glycemic excursions (MAGEs), and continuous overlapping net glycemic action (CONGA) were assessed in a subset of patients who injected insulin alternately in LH and non-LH sites.

RESULTS

The overall prevalence of LH was 69.8%, and was significantly higher in adults than in children (P = 0.038). Improper rotation of sites (P < 0.0001) and insulin syringe reusage for more than five times (P = 0.009) significantly increase the risk of LH. The presence of LH has a significant effect on GV and UH with adjusted odds ratios of 17.65 (P < 0.0001) and 28.02 (P < 0.0001), respectively. Ambulatory glucose monitoring on a subset of patients confirmed that the mean glucose, MAGE, and CONGA were higher when subjects injected insulin at LH sites than at non-LH sites.

CONCLUSIONS

Improper rotation of sites and reuse of needles are the leading causes of LH in Indian T1DM patients, which, in turn, significantly increases the risk of GV and UH.

Errors in insulin treatment management and risk of lipohypertrophy

AIMS

Lipohypertrophy (LH) represents the most common skin-related complication associated with insulin therapy. Our aim is to estimate the prevalence of LH among insulin-treated patients, to identify its association with errors in insulin injection technique and storage, and the correlation between LH, risk of hypoglycemia, and glycemic control.

METHODS

Consecutive patients with T1DM or T2DM, attending a diabetes clinic for a routine visit, were administered an anonymous questionnaire investigating the modalities of insulin injection, the correct use of pen device, insulin storage, and reported frequency of hypoglycemic episodes. The presence of LH was assessed by inspection and palpation of injection sites.

RESULTS

Overall, 352 patients were enrolled (mean age 68 ± 12 years, 43.2% males, 88.9% with T2DM, mean duration of insulin therapy 9.1 ± 8.6 years). The prevalence of LH was 42.9%. At multivariate analysis, the strongest correlates of LH were not spacing injections (OR 20.4; 95% CI 10.5-39.6) and not rotating the site of injection (OR 2.01; 95% CI 1.08-3.75). Increasing doses of insulin and longer duration of insulin therapy also increased the risk of LH. The presence of LH was associated with a 2.7 times higher risk of severe hypoglycemia. Higher daily insulin doses, lack of rotation of injection sites, and keeping insulin in use in the refrigerator were independent correlates of higher HbA1c levels.

CONCLUSIONS

Insulin injection technique is suboptimal in many patients, highlighting the need for improved patient education. Increasing the awareness of the importance of preventing lipohypertrophy and insulin injection errors represents an important tool to reduce the clinical, social, and economic burden of diabetes.

Insulin Injection Site Adverse Effect in a Type 1 Diabetes Patient: An Unusual Presentation

Insulin is an integral part of Type 1 diabetes management. Patient education is of utmost importance to ensure proper injection technique for getting appropriate glycaemic control as well as to avoid injection site adverse effects. Commonest injection site adverse effect is lipodystrophy, attributable to localized manifestation of the pharmacological action of insulin. However, we present a case where incorrect injection technique led to an unusual presentation of injection site adverse effect. Apart from the abnormal skin changes, the incorrect technique also adversely affected the glycaemic control. Though less prominent, some marks are still evident one and a half years after correction of the injection technique. However, the glycaemic control has substantially improved. This emphasizes the need of proper patient education regarding insulin injection technique.

Unexplained Persistent Hyperglycaemia in a Type I Diabetes Patient - Is Injection Site Lipohypertrophy the Cause?

Type I diabetes patients depend on insulin injections. Proper injection technique is essential for good glycaemic control. Incorrect technique can also lead to local injection site adverse effects, commonest being lipohypertrophy. Hypoglycaemia, by far the most dreaded adverse effect of insulin, receives utmost focus in management of patients on insulin. Lipohypertrophy, on the other hand, is a relatively neglected adverse effect. It is necessary for health care providers to realize that it can also have serious clinical implications. We present a case of persistent unexplained hyperglycaemia in a Type I Diabetes Mellitus (TIDM) patient with severe injection site lipohypertropy. After switching to normal unused sites, her blood sugar levels improved, along with reduction in insulin requirement. The case highlights the importance of continuous patient education and alert monitoring by health care providers.