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CPD ACTIVITY 61 ADVISING ON INSULIN NEEDLE SELECTION AND INJECTION TECHNIQUE Sofia Cabrera BPharm (Hons) AACPA Accredited Pharmacist LEARNING OJECTIVES After completing this CPD activity, pharmacists should be able to: • Describe the appropriate injection technique for insulin. • Describe potential complications of incorrect insulin administration. • Educate patients on the proper use of insulin needles. 2016 Competency Standards: 2.1, 2.2, 2.3, 3.1, 3.3, 3.5. Accreditation Number: A2007RP1 (exp: 30/06/2022). Insulin injection technique Pharmacists can play a vital role in providing education to patients on correct insulin injection technique. Insulin is delivered via injection subcutaneously with an insulin pen, insulin syringe or a continuous subcutaneous insulin infusion (insulin pump) for patients with type 1, type 2 and gestational diabetes. Insulin pens became available in Australia in 1985 and are currently the most popular method of insulin administration.1 This article will focus on insulin pen needles and syringes. The Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) was released in 2016. These are considered gold standard recommendations for optimising insulin delivery.2 The recommendations have since been adopted into the national guidelines of many countries, including Australia.2 FITTER focuses on several key areas, including injection sites and injection technique. Injection technique encompasses many factors including: • Site of administration. • Correct needle length. • Correct angle of injection. • Use of skin folds. • The duration of time the needle remains under the skin. Following correct insulin injection technique will help ensure insulin is administered subcutaneously at the prescribed dose and reduce complications. Injecting complications Incorrect insulin injection can lead to complications. These can be minimised with correct technique. Inadvertent intramuscular injection Inadvertent intramuscular rather than subcutaneous insulin injection can cause:1 • Hypoglycaemia with either rapid onset or lengthened duration of insulin. • Variation in insulin absorption between injections. • Variation in insulin uptake and duration of action. • Fluctuations in metabolic control. Causes of inadvertent intramuscular injection include use of inappropriately long needles, ie, pen needles ≥6mm and syringes >6mm,1,10 and incorrect injection technique, eg, problems with angle of administration, site of administration and skin folds.1 Lipodystrophy Lipodystrophy is a disorder of fat tissue most commonly presenting as lipoatrophy or lipohypertrophy.2 Lipoatrophy is retracted scarring that is often large and deep as a result of subcutaneous damage. Lipohypertrophy is a raised, thickened, rubbery tissue which is often firm to touch. It is estimated to affect between 29 per cent and 64.4 per cent of all patients who inject insulin.4 (Figure 1) Lipohypertrophy can cause:1 Figure 1: Lypohypertrophy of the abdomen. • Erratic or delayed absorption of insulin. • Unexplained hyperglycaemia. • Unexplained hypoglycaemia. Lipohypertrophy can occur in all patients who inject insulin. However, it’s more frequent in patients who:3 • Have high frequency insulin use. • Have long duration of insulin use. • Don’t rotate insulin sites. • Have a high total daily dose of insulin. • Reuse insulin needles. Visual inspection and palpation for lipohypertrophy can be conducted by healthcare professionals.3 However, it may not be in the routine scope of practice for a pharmacist to perform a physical examination (by palpation). If a pharmacist suspects a patient has lipohypertrophy, onward referral to a diabetes educator is required. Patients should be educated to self-assess for lipohypertrophy and inject away from any areas that are affected. If a patient has been injecting insulin into an area of lipohypertrophy and plans to move to an unaffected site, they will require a dose reduction of insulin of usually 20 to 50 per cent to avoid potential hypoglycaemia under guidance of a healthcare professional.1 Lipohypertrophy will generally return to normal after injecting into affected sites has ceased. However, if the skin doesn’t return to normal, patients should be referred on to their GP to ensure it’s not something more serious, such as amyloidosis.2 TO PAGE 62 RETAIL PHARMACY • JUL 2020 2 CPD CREDITS