New research says there are better ways to inject insulin with a syringe, as well as manage infusion sites, to get the most out of your insulin and improve diabetes care.
“Our research has previously shown that, among others things, so long as they deposit or infuse insulin into the subcutaneous fat, the length of the needle and infusion catheter are not important in terms of insulin absorption. However, poor site rotation for injection and for infusion catheters is strongly associated with lipohypertrophy –—enlargement of the fat cells — which significantly and negatively affects the rate and consistency of insulin absorption,” says Dr. Laurence Hirsch, Vice President of Global Medical Affairs for the Diabetes Care business at Becton, Dickson, and Company (better known as BD). BD is the manufacturer of syringes, pen needles, and infusion sets that sponsored the research leading to three articles (all Open Access) being published in the September 2016 issue of the Mayo Clinic Proceedings. “These findings led us to make specific recommendations on how to improve insulin delivery, including using shorter needles, not reusing needles as often, and rotating injection (and infusion) sites properly.”
If anyone should know about how syringes impact diabetes care, it’s Dr. Hirsch. One of a baker’s dozen who wrote the articles detailing the findings in the Mayo Clinical Proceedings, Dr. Hirsch has had type 1 diabetes for almost 59 years. He used to use a glass syringe with a luer hub, sharpening the bare steel needle on a whetstone, back in the days before disposable syringes were even invented.
The findings he spoke about grew out of an international congress of 183 diabetes experts from 54 countries who met at a workshop in Italy in October 2015 to examine insulin delivery techniques with the idea of improving how insulin is injected and infused. It was the most comprehensive gathering of experts convened to examine the ways in which insulin is physically introduced to the body through needles and infusion sets.
“Syringes are sort of the Rodney Dangerfield of diabetes,” Dr. Hirsch says. “They don’t get no respect. But, their proper use is very important to ensuring optimal diabetes care.” The publications are based on the nearly 13,300-patient Injection Technique Questionnaire (ITQ) survey, from 423 centers in 42 countries. Two of the articles present the findings from the survey, which describe current practices and problems; the third is the New Recommendations, sort of the answers to the problems.
What the conference, called FITTER, or the Forum for Injection Technique and Therapy Injection Recommendations, found was:
- Many people with diabetes were using needles that were too long and, instead of delivering insulin into the fat below the skin, they may have been at high risk of delivering insulin to the muscle, where absorption can be very variable, and might happen very quickly. “If a needle is so long that it goes into the muscle, then all bets are off regarding the rate of absorption. There’s a much higher possibility of rapid uptake and hypoglycemia, and other adverse issues,” according to Dr. Hirsch;
- One-third of the survey respondents were injecting or infusing insulin into fat nodules, called lipohypertrophy (or lipos), that come about because of improper site rotation for injections and infusion site selection;
- Needle reuse is also linked to developing lipohypertrophy.
“Lipohypertrophy can be serious,” Dr. Hirsch says. “It’s an enlargement of fat cells that clinically appears as a hardening under the skin that feels rubbery, or like a cluster of grapes. It can get so substantial for some people that it inhibits the absorption of insulin, and makes it much less consistent. The last thing you want if you’re taking insulin is to have variability in its absorption.”
Based on the findings the FITTER panel made the following recommendations to improve the effectiveness of insulin delivery:
- Use shorter needles, such as 6 mm with syringes or 4 mm with pens, to avoid sending the insulin to the muscle (smaller needles also hurt less, and patients prefer them);
- Rotate injection and infusion sites more rigorously around the body – between sites and within sites; not, for example, just from one thigh to the other thigh, or one side of the abdomen to the other, over and over and over;
- Have your doctor or medical professional check for lipohypertrophy at injection/infusion sites and avoid those sites if lipo is present;
- Use disposable syringes and pen needles only one time.
“I think these new recommendations are more evolutionary than revolutionary,” Dr. Hirsch says. “But we came about these recommendations through rigorous research with the ITQ survey. We analyzed all that data and we published the findings and recommendations in a high-quality, peer-reviewed medical journal.”
Despite this rigor, Dr. Hirsch admits—while also defending—that some may criticize the advice about needle reuse, due to BD’s interest as a manufacturer of pen needles and syringes.
“Yes, I get it,” Dr. Hirsch says. “But, it’s not just a needle company saying buy more needles. It’s a vast array of diabetes experts who came together and arrived at these conclusions. These recommendations are supported by the data, and there is a huge amount of it.”
The ITQ data, and the recommendations, highlight just how important it is to use pens and pen needles, as well as syringes and infusion sets correctly in order to provide the best diabetes care possible, Dr. Hirsch says.
“The disposable syringe changed life for all patients taking insulin,” he says. “I used to use a 25 gauge, 16 mm, steel needle with a luer attachment to the glass syringe – which we had to boil to sterilize every 2 to 3 days. But, once BD introduced plastic, disposable syringes it meant I could travel. I wasn’t tied to the house or to my parents to deliver my insulin. It was liberating.”
But, he said, just having access to disposable syringes and small pen needles is not the end of the story because there are right, and wrong ways, to properly use such innovative tools.
“We’re going to get out on the road with this information and educate doctors, nurses, educators, and patients,” Dr. Hirsch says. “We’re doing it because it’s important and because we can help people.”