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The Importance of Good Insulin Injection Practices in Diabetes Management
it breaking off and lodging under the skin.
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If needles are re-used,
Table 2: Risk Factors and Related Increases in the
insulin can deposit within the needle, making it harder to press on the
Incidence of Lipohypertrophy
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plunger and deliver the proper dose of insulin. Insulin syringes need to
be filled prior to use. Therefore, the syringe needles will pass through the Needle Re-use
rubber stoppers of insulin vials in order to draw up the insulin prior to Needle Change Frequency Incidence of Lipohypertrophy (%)
being injected into the patient. Pen needles are not exposed to this Every injection 20.3
trauma because the insulin pens are pre-filled.
Every 2–3 injections 51.2
Every 4–5 injections 75
Contamination
After the insulin pen cartridge is empty 100
Although sterility is guaranteed with the first use of the syringe and pen
Injection Site
needles, the potential for contamination increases with repeated use.
Change of Site Frequency Incidence of Lipohypertrophy (%)
One study showed biological material was trapped in the pen needles or
Rotated weekly 23.8
cartridges of 62% of patients after injection.
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Bacteriostatic agents are
Each injection 76.9
added to most insulins to stop bacterial growth; however, needle re-use
No change—one injection site used 86
Random injection sites 90.5
can increase the risk of infection.
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Duration of Insulin Use
Infections caused by contamination from needle re-use can be severe.
Duration of Insulin Use (years) Incidence of Lipohypertrophy (%)
Some infections can even be life-threatening, as for example in the
<5 12.1
6–10 40.7
reported case of a perinephric abscess due to insulin syringe re-use.
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11–15 77.2
Those patients who have compromised immune systems are likely to be
16–20 84.8
at a higher risk for such infections, as are those with infected skin
lesions who do not practice good hygiene.
4
Some patients, in an attempt
to be hygienic, will clean the needle with alcohol prior to re-using it. promoting effects of insulin, resulting in a lower incidence of
Doing so, however, will remove the silicone lubricant, which will result in lipohypertrophy. Unfortunately, patients tend to repeatedly inject at
a more painful injection.
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sites of lipohypertrophy because it is less painful to do so. This in turn
further exacerbates the problem.
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Dosage Accuracy
Insulin pen delivery systems are extremely accurate when used Lipodystrophy—scarring of the fat—is thought to be secondary to the
properly.
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If the needles are left on the pens after use, however, air can trauma caused by needle re-use and also to giving repeated insulin
pass through them into the insulin chamber. Not only can this increase injections at the same site.
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To minimize lipohypertrophy and
the chance of contamination, it can also affect dosage accuracy due to lipodystrophy, needles should not be re-used and injection sites should
air bubble formation. The excess air reduces ‘the delivery of insulin in be rotated correctly. Lipoatrophy is manifested by a loss of
the five seconds that patients normally wait’ when using their insulin subcutaneous fat. In some patients it has been associated with impure
pen.
30
According to this study, if a pen were to have 200µl of air in it, a insulins and presents as a depression in the skin. Checks should be
patient would receive only 37% of his or her dose. Thus, a patient who made for any signs of lipohypertrophy, lipodystrophy, and lipoatrophy
intended to take 20 units of insulin would receive only 7.4 units if the during routine examinations of patients with diabetes. Once identified,
needle was withdrawn after the standard five-second wait. This is why corrective action should be initiated.
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manufacturers recommend removing insulin pen needles immediately
after use. In light of this it is also reasonable to have patients wait Trypanophobia
10 seconds rather than five if they are injecting more than 25 units of Trypanophobia is more commonly known as ‘needle phobia.’ Despite
insulin with a 30-gauge or smaller needle. numerous advances in the technology of insulin syringes and pens, there
are still patients who are reluctant to take insulin injections. For a brief
Lipohypertrophy, Lipodystrophy, and Lipoatrophy period when inhaled insulins were on the market, such patients could be
Lipohypertrophy is the most common local complication of insulin use. placed on these alternatives. Such insulins are no longer available, thus
It presents as ‘grape-like’ lumps of excessive fat at insulin injection the issue of ‘needle phobia’ needs to be addressed.
sites. The factors that were found to be statistically relevent to the
incidence of lipohypertrophy include needle change frequency, One or more of the following factors is often involved in a patient’s
change of site frequency, and duration of insulin use (see Table 2).
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needle phobia:
The re-use and repeated use of insulin needles causes damage to their
tips and a loss of the silicone lubricant, resulting in damage to the • a perceived loss of control over his/her life;
tissue by the injections and an increased likelihood of lipohypertrophy • a lack of confidence that he/she could handle the demands of
occurring. Lipohypertrophy was noted to occur least in patients who insulin therapy;
rotated their injection sites weekly (see Table 2). These findings • a belief that insulin therapy equates to a personal failure;
suggest that the form of rotation is important. By rotating properly • a perception that the diabetes has become much worse;
among injection sites it will be weeks before the patient returns to the • injection-related anxiety; and
original site. During this time the site will be free from the growth- • a perceived lack of personal gain.
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US ENDOCRINOLOGY 51
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