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Review Article

Addendum 2

Forum for Injection Technique, India

Kalra, Sanjay; Balhara, Yatan Pal Singh1; Baruah, Manash P.2; Chadha, Manoj3; Chandalia, Hemraj B.4; Chowdhury, Subhankar5; Kesavadev, Jothydev6; Prasanna Kumar, K. M.7; Modi, Sonal8; Pitale, Shailesh9; Rishi, Shukla10; Sahay, Rakesh11; Sundaram, Annamalai12; Unnikrishnan, Ambika G.13; Wangnoo, Subhash K.14

Author Information
Indian Journal of Endocrinology and Metabolism: Nov–Dec 2014 - Volume 18 - Issue 6 - p 800-803
doi: 10.4103/2230-8210.141344
  • Open

Abstract

INTRODUCTION

The Forum for Injection Technique (FIT), India, recommendations were published in 2012 as a guide to the science and art of insulin injection technique. These recommendations have enhanced awareness about the importance of appropriate insulin technique in insulin and diabetes therapy in India. The FIT India recommendations writing group also published an addendum in 2013, covering aspects of insulin technique, which had not received due coverage in the original document. At the same time, it was planned to review the original recommendations at regular, preferably yearly, intervals, to assess the need for further addenda.

With this mandate, a second addendum of the FIT India recommendations is being published this year. This addendum, as the previous one, should be read in conjunction with the original document. Apart from the additions related to injection – meal interval of glucagon-like peptide 1 receptor agonists, methods of minimizing pain during injections, amyloidosis, and factors that impact adherence were also added; the original manuscript has undergone extensive language editing. Important changes include substitution of the word ‘compliance’ with ‘adherence’ and of ‘diabetics’ with ‘persons with diabetes’, to reflect current semantics. Section 4.0 also highlights that the impact of so-called non-modifiable factors, which influence injection technique can be modulated, positively, by appropriate choice of modern insulin devices.

SEMANTIC CHANGES

Certain substitutions have been made into the original FIT recommendations, 2012, to keep the document consonant with modern terminology.

These include the use of ‘glucagon-like peptide-1 receptor agonists’, ‘adherence’, and ‘persons with diabetes’, in place of the earlier terms: glucagon-like peptide-1 analogs, compliance, and diabetics.

Need for Indian guidelines

Several factors influence the success of insulin injection therapy, injection technique being one of them. However injection technique is highly variable and operator-dependent.

FACTORS INFLUENCING INJECTION TECHNIQUE

The factors that influence injection technique are classified in Table 1.

T1-9
Table 1:
Factors influencing injection technique

There are some factors like dexterity, visual impairment, auditory impairment and learning skills, which cannot be modified, at least in the context of treatment initiation, where promptness plays a key role. These factors can be addressed, however, by choosing appropriate insulin devices, suited to the individual. For example, modern pens with magnified dose display, audible clicks to inform dose increments, and lower pressure requirements for plunging, can be helpful in differently-abled individuals. Guidelines are required to optimize the factors listed above [Table 6.13.1], and to ensure appropriate practice of insulin injection technique by both health care professionals and people with diabetes.

T2-9
Table 6131:
Minimizing pain associated with insulin

GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS (GLP1RA)

The frequency and timing in relation to meal may vary among the available GLP1RA. Exenatide is administered twice daily, 30 minutes before meals. Liraglutide is injected once daily, without regard to meal timings. Some physicians advise liraglutide at bed time to reduce gastrointestinal discomfort. Long-acting release (LAR) exenatide is injected with a thick gauge needle, once a week, at any time of the day.

CORRECT SITE ROTATION

Correct site rotation is defined as administering insulin injections at least 1 cm apart, in a systematic manner, to avoid repeated local tissue damage, while ensuring stable insulin absorption.

In a study to assess the frequency of LH and its relationship to site rotation, needle reuse, glucose variability, hypoglycemia and use of insulin on 430 outpatients injecting insulin, it was found that nearly two-thirds (64.4%) of patients had LH. There was a strong relationship between the presence of LH and non-rotation of sites, with correct rotation technique having the strongest protective value against LH [Table 2]. Of the patients who correctly rotated sites, only 5% had LH, while of the patients with LH, 98% either did not rotate sites or rotated incorrectly. Also, 39.1% of patients with LH had unexplained hypoglycemia and 49.1% had glycemic variability compared with only 5.9% and 6.5%, respectively, in those without LH. LH was also related to needle reuse, with risk increasing significantly when needles were used >5 times.[1]

T3-9
Table 2:
Lipohypertrophy

Total daily insulin doses for patients with and without LH averaged 56 and 41 IU/day, respectively. This 15 IU difference equates to a total annual cost to the Spanish health care system of >122 million.[1]

According to this study, correct injection site rotation appeared to be the critical factor in preventing LH, associated with reduced glucose variability, hypoglycemia, insulin consumption and costs.[1]

AMYLOIDOSIS

Amyloidosis is a systemic or local disease in which amyloid substances are deposited extracellularly and impair tissue function.

It has been shown that local amyloid deposition very infrequently takes place at the site of repeated insulin injection in patients with insulin-requiring diabetes.[234]

The amyloid at the injected site was identified as amyloid insulin type (A-Ins). The nature of amyloid in the insulin injection site is considered to be insulin itself or insulin-related substance.[56789]

Previously amyloid formation was suspected to be correlated with non-human insulin products, in particular those of porcine origin. However, there are newer cases where the use was limited to only human recombinant insulin or human insulin semi-synthetic analog, and therefore the species of insulin does not seem to be a major reason for the amyloidogenesis in insulin injected sites.[10]

Some of the reported cases were insulin resistant with elevated HbA1c levels.

Blood glucose control becomes markedly improved shortly after resection of the tumor or after the change of the injection site and the presence of the amyloid mass itself perhaps due to poor penetration of insulin, which may have contributed to the insulin resistance or in other words, refractoriness of insulin treatment.

The reported cases emphasize the necessity for the patient care staff to regularly check-up on the insulin injection site to prevent infection, inflammation or mass formation, and patient education for the alternate use of insulin injection site.

Insulin-related factors

  • Appropriate insulin regime
  • Appropriate insulin dose
  • Efficacy
  • Safety (no or minimal hypoglycemia)
  • Tolerability (no weight gain)
  • Flexibility (in timing of injection)
  • Consistency (in action profile).

Device-related factors

  • Ease of use
  • Ease of carrying
  • Social acceptability
  • Ease of maintenance.

The expert committee feels that the above updates are essential and are necessary to ensure appropriate practice of insulin injection technique by both health care professionals and people with diabetes.

REFERENCES

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2. Dische FE, Wernstedt C, Westermark GT, Westermark P, Pepys MB, Rennie JA, et al Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient Diabetologia. 1988;31:158–61
3. Swift B. Examination of insulin injection sites: An unexpected finding of localized amyloidosis Diabet Med. 2002;19:881–2
4. Albert SG, Obadiah J, Parseghian SA, Yadira Hurley M, Mooradian AD. Severe insulin resistance associated with subcutaneous amyloid deposition Diabetes Res Clin Pract. 2007;75:374–6
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7. Dische FE, Wernstedt C, Westermark GT, Westermark P, Pepys MB, Rennie JA, et al Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient Diabetologia. 1988;31:158–61
8. Swift B. Examination of insulin injection sites: An unexpected finding of localized amyloidosis Diabet Med. 2002;19:881–2
9. Albert SG, Obadiah J, Parseghian SA, Yadira Hurley M, Mooradian AD. Severe insulin resistance associated with subcutaneous amyloid deposition Diabetes Res Clin Pract. 2007;75:374–6
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    12. Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al International DAWN Advisory Panel. Resistance to insulin therapy among patients and providers: Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study Diabetes Care. 2005;28:2673–9
      13. Brod M, Kongso JH, Lessard S, Christensen TL. Psychological insulin resistance: Patient beliefs and implication for diabetes management Qual Life Res. 2009;18:23–32
        14. Brod M, Kongso JH, Lessard S, Christensen TL. Psychological insulin resistance: Patient beliefs and implication for diabetes management Qual Life Res. 2009;18:23–32
          15. Bärtsch U, Comtesse C, Wetekam B. Injectable therapy pen devices for reatment of diabetes (article in German) Ther Umsch. 2006;63:398–404
            16. Saez-de Ibarra L, Gallego F. Factors related to lypohypertrophy in insulin treated Diabetic Patients; role of educational intervention Pract Diabetes Int. 1998;5:9–11

              Source of Support: Nil

              Conflict of Interest: None declared.

              Keywords:

              Degludec; exenatide; exenatide LAR; Glucagon like peptide-1 receptor agonists; liraglutide

              © 2014 Indian Journal of Endocrinology and Metabolism | Published by Wolters Kluwer – Medknow