New injection recommendations for patients with diabetes

Abstract

Aim

Injections administered by patients are one of the mainstays of diabetes management. Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy. Yet few formal guidelines have been published summarizing all that is known about best practice. We propose new injection guidelines which are thoroughly evidence-based, written and vetted by a large group of international injection experts.

Methods

A systematic literature study was conducted for all peer-reviewed studies and publications which bear on injections in diabetes. An international group of experts met regularly over a two-year period to review this literature and draft the recommendations. These were then presented for review and revision to 127 experts from 27 countries at the TITAN workshop in September, 2009.

Results

Of 292 articles reviewed, 157 were found to meet the criteria of relevance to the recommendations. Each recommendation was graded by the weight it should have in daily practice and by its degree of support in the medical literature. The topics covered include The Role of the Professional, Psychological Challenges, Education, Site Care, Storage, Suspension and Priming, Injecting Process, Proper Use of Pens and Syringes, Insulin analogues, Human and Pre-mixed Insulins, GLP-1 analogs, Needle Length, Skin Folds, Lipohypertrophy, Rotation, Bleeding and Bruising, Pregnancy, Safety and Disposal.

Conclusion

These injecting recommendations provide practical guidance and fill an important gap in diabetes management. If followed, they should help ensure comfortable, effective and largely complication-free injections.

Résumé

Objectif

Les injections que réalisent les patients atteints de diabète sont l’un des piliers de la gestion de la maladie. Une bonne technique d’injection est essentielle pour éviter les injections intramusculaires, pour délivrer le produit injecté de manière appropriée aux tissus sous-cutanés et pour éviter les complications courantes telles que la lipohypertrophie. Pourtant, peu de recommandations officielles résumant tout ce qui est connu des meilleures pratiques ont été publiées. Nous proposons des nouvelles lignes directrices concernant les injections, fondées sur des preuves publiées et validées par un large groupe d’experts internationaux.

Méthodes

Une étude systématique de toutes les études et publications qui portaient sur le thème des injections chez les diabétiques a été effectuée. Un groupe d’experts internationaux s’est réuni régulièrement durant deux ans pour examiner ce projet et rédiger des recommandations. Celles-ci ont ensuite été soumises pour examen et révision à 127 experts de 27 pays lors de l’atelier TITAN en Septembre 2009.

Résultats

Sur les 292 articles examinés, 157 ont été jugés conformes aux critères de pertinence pour les recommandations. Chaque recommandation a été classée selon l’importance qu’elle devait avoir dans la pratique quotidienne et par son niveau de preuve dans la littérature médicale. Les sujets abordés comprennent le rôle des professionnels de santé, les aspects psychologiques des injections, l’éducation, la préparation du point d’injection, le stockage et la remise en suspension de l’insuline, les étapes de l’injection, l’utilisation correcte des stylos et des seringues, les analogues de l’insuline, les insulines humaines et les insulines pré-mélangées, les analogues de GLP-1, la longueur de l’aiguille, le pli cutané, les lipohypertrophies, la rotation des points d’injection, les hématomes et les saignements, la grossesse, la sécurité des soignants et l’élimination des déchets.

Conclusion

Ces recommandations et ces conseils pratiques qui concernent les injections comblent une lacune importante dans la prise en charge du diabète. Si elles étaient suivies, elles devraient contribuer à assurer des injections confortables, efficaces et la plupart du temps dénuées de complications.

Introduction

This paper presents new injection recommendations for patients with diabetes based on the latest studies and publications in the field. While much attention has been paid to the pharmacokinetic and pharmacodynamic properties of diabetes therapies, not enough is given to achieving the most comfortable, consistent subcutaneous (SC) delivery of the injected medication. Correct injection technique is critical for optimal control of diabetes.

In recent years there has been a major shift towards shorter-length needles as studies proving their safety, efficacy and user preference have been published [1,2], presentations given at meetings [3,4] and guidelines issued [5], [6], [7], [8]. Clear recommendations regarding the use of such needles in specific patient populations have however been lacking. This paper attempts to provide such guidance. In addition, these recommendations cover issues not previously addressed, such as psychological barriers to insulin therapy, appropriate injection technique with the newer insulin analogues and GLP-1 agents, and the prevention of injecting complications such as needle stick injuries and lipodystrophy [6], [7], [8].

The new recommendations were informed by the results of the second Injection Technique Questionnaire (ITQ) survey. Over 8 months, from September 2008 to June 2009, more than 4300 insulin-injecting patients with diabetes from 171 centers in 16 countries participated in the survey, making it one of the largest multi-center studies of its kind in diabetes. The results of this survey had just become available as the new recommendations were being formulated.

The survey results and an initial draft of the new recommendations were presented at the Third Injection Technique workshop in AtheNs (TITAN) held in Athens, Greece, on 10-13 September, 2009, at which 127 doctors, nurses, educators and psychologists from 27 countries (see Appendix) met to discuss and debate these proposals. The new recommendations were significantly reshaped by the collective input of this group.