All about injections

Get a better understanding of insulin and other injectable medications.

Best Practices in Injection Technique

A healthcare professional trained in injection techniques can teach you how to do it right

The following recommendations apply to people with diabetes being treated with insulin injections or GLP-1 analogues (albiglutide (EperzanTM), dulaglutide (Trulicity®), exenatide (Byetta®), exenatide sustained release (Bydureon®) and liraglutide (Victoza®)). They are based on the Recommendations for Best Practice in Injection Technique (2015) from the Forum for Injection Technique (FIT).

Preparing for injection

Follow these important steps before an injection:

  • Wash your hands and the injection site with soap and water, and dry well.
  • If you use an alcohol swab (e.g.: in a hospital), let the skin dry completely before administering the injection.
  • Check that the vial or cartridge has not passed its expiration date.
  • Wipe the cartridge or vial with an alcohol swab.

When using cloudy insulin, gently roll the cartridge, vial or pen device 10 times, then tip it (do not shake) 10 times. Finally, inspect it to ensure that the suspension has a consistently milky white appearance.

Is a skin lift necessary?

In adults, a skin lift is used in some situations, based on needle length and the amount of adipose (fat) tissue. A skin lift should be used when the needle is 8 mm or longer. In addition, in people whose arms and legs or abdomen have little fatty tissue, a skin fold might be justified when using a needle of 5 mm or 6 mm. A skinfold may not be necessary especially when using a 4 mm needle .

A skin lift, if required, must be done properly to ensure that the medication is not injected into the muscle or not deeply enough.

Injection areas

In adults, the recommended injection areas are the following:

  • abdomen
  • thighs
  • upper buttocks
  • back of the upper arm (not a preferred area because of the difficulty reaching it when self-injecting)

Insulin absorption can vary due to several factors, including the insulin injection sites. Insulin is absorbed more quickly when injected into the abdomen, compared to average absorption in the arms and thighs. The buttocks absorb insulin more slowly. GLP-1 analogues, on the other hand, appear to be absorbed at the same rate in the usual injection sites (abdomen, arms, and thighs).

Injecting insulin into an area used during physical activity may increase insulin absorption, resulting in faster action and a decrease in blood glucose (sugar) levels.

 

 

The rotation of injection areas and sites

To avoid the formation of skin dents and lumps (lipodystrophy) and to ensure consistent insulin absorption:

  • Use a new needle for every injection.
  • Regularly examine and palpate your injection areas for any signs of lipodystrophy.
  • Vary the injection area and use a structured rotation within the same injection area.

Rotating anatomical areas

Insulin absorption varies from one anatomical region to another. Therefore, varying the regions is recommended, while reserving the same anatomical region for a particular time of day. For example, you can use the abdomen at breakfast and lunch, then the thighs at supper and bedtime.

Rotating injection sites

A structured rotation is recommended within the same anatomical region, leaving at least 1 to 2 cm (1 finger width) between each site and not using the same site for a month. For the abdomen, care should be taken to avoid injecting within 2 to 3 cm from the umbilicus (belly button).

To help you do this, divide each anatomical area into quadrants (four zones) and rotate the injection sites within the same quadrant for a week. Do likewise for the other three quadrants.

Avoiding pain

Some tips for making injections more comfortable:

  • Use short needles (4 mm, 5 mm or 6 mm) to avoid intramuscular injections.
  • Use a new needle for every injection.
  • Keep injectable medication currently in use at room temperature.
  • Avoid injecting into hair roots, scars, beauty marks or any other skin abnormality.
  • If you use alcohol swabs, inject only after the alcohol has completely evaporated and the skin is dry.
  • Insert the needle through the skin using a quick, smooth movement, then inject the medication slowly and evenly.

If, despite these tips, injections are still painful, consult a healthcare professional, who can check your technique and, if required, suggest other measures.

Storing insulin

Once a vial or cartridge has been opened, it should not be used for more than 28 days (42 days for insulin detemir). Unopened vial or cartridge of insulin should be stored in the refrigerator (2 to 8oC). Insulin should never be frozen or exposed to extreme heat (above 30 C) as this will affect its potency and alter its action.

After injecting, safely dispose of the needle and all sharps in an approved biomedical disposal container.

 

Research and adaptation: Diabetes Québec Team of Healthcare Professionals

Adapted from:

Tremblay Louise, Nurse (Summer 2012), “Les meilleures pratiques… pour la technique d’injection,” Plein Soleil, Diabetes Québec, pp. 31-33. Revised by Françoise Desrochers, Nurse., B.Sc.

Reference:

Forum for Injection Technique – FIT Canada: Recommendations for Best Practice in Injection [Online]. Found at:  http://www.fit4diabetes.com/files/5314/2071/1987/FIT_Recommendations_Page_View_En.pdf

©All rights reserved, Diabetes Québec 2019

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Lipohypertrophy

Even when not visible, lipohypertrophy can affect the absorption of insulin and thus your blood glucose control.

Lipohypertrophy is characterized by a thickening of the subcutaneous (under the skin) fatty tissue, which can create hard, raised lumps on the surface of the skin. This can occur if you inject insulin in the same spot over time or if you use the same needle more than once.

According to an international survey on injection techniques, 47% of diabetic patients have experienced lipohypertrophy due to repeated injections in an area about the size of a postage stamp.

Because lipohypertrophy reduces the skin’s sensitivity, many people tend to inject in this less painful spot. However, you must avoid injecting in areas with lumps or other abnormalities.

The consequences of lipohypertrophy

The implications go beyond mere aesthetics. Even when not visible, lipohypertrophy can affect the absorption of insulin and thus your blood glucose control.

Someone who regularly injects in a lipohypertrophic (lumpy) area could experience the following:

  • Great variability in blood glucose (sugar) levels
  • Higher A1C (glycated hemoglobin) results
  • Frequent and unexplained hypoglycemia (low blood sugar)
  • High or frequently increased insulin dosages

How to detect it?

  • Visually inspect injection areas, and try to spot a bump;
  • Palpate the skin of your injection area by making a circular sweep with your fingers, and press the areas where you usually do your injection;
  • In the presence of lipohypertrophy, the skin will have a different texture (rubbery bump, denser tissue).

In doubt, do not hesitate to consult a member of your care team who will be able to examine your injection areas and suggest a plan of action if necessary.

How to prevent lipohypertrophy?

To prevent lipohypertrophy, you should vary the anatomical regions (the areas of your body) as well as the injection points (where the needle enters your body). You should always use a new needle for every injection.

A few extra precautions

If you were used to inject in the same spot and have now started to rotate anatomical regions and injections points, you may find that your insulin dosage needs to be adjusted to prevent hypoglycemia. You should discuss this with a health care professional and monitor your blood sugar levels more frequently when you make the switch.

Finally, it is essential to regularly palpate your injection sites and ask a health care professional to do so at your follow up appointments, in order to detect any abnormalities.

 

Research and redaction: Diabetes Québec Team of Healthcare Professionals

Reference:

Forum for Injection Technique – FIT Canada: Recommendations for Best Practice in Injection [Online]. Found at:  http://www.fit4diabetes.com/files/5314/2071/1987/FIT_Recommendations_Page_View_En.pdf

©All rights reserved, Diabetes Québec 2019

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Is there a Maximum Amount of Insulin for a Single Injection?

According to the Recommendations for Best Practice in Injection Technique (FIT 2015), for some types of insulin, the greater the volume injected, the more delayed their action will be. This is particularly true for short-acting insulin (Humulin R® and Novolin ge Toronto®), intermediate-acting insulin (Novolin ge NPH ® and Humulin N®). Consequently, for insulin injections above 50 units, it would be better to split the dose into several injections to maximize the effect of the insulin, as well as to avoid discomfort or insulin leakage.

As for long-acting insulin analogues (Lantus®, Levemir®), their time-action profile does not appear to be affected by the volume of the injection. However, if a large amount of this type of insulin is injected, it could cause insulin leakage and discomfort at the injection site.

 

Research and text: Amélie Roy-Fleming, Dietitian and Certified Diabetes Educator

Diabetes Québec, November 2019

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Injecting Insulin in Public

When people know more about diabetes and insulin, they are able to understand and accept the situation.

A person being treated with insulin will need to self-administer it in various public places.

Since there is still a great deal of ignorance about diabetes among the general population, it is normal that some people will feel uncomfortable with a practice they don’t understand. If these are people you know, explaining the disease and your need for insulin therapy can help change their point of view.

Very often, when people know more about it, they are able to understand and accept the situation.

Be discreet

When injections are done discreetly, the people around barely notice. Most people with diabetes now use insulin pen injectors instead of syringes. This helps make injections less obvious. Due to its familiar shape, the pen injector helps take the drama out of insulin therapy for people who are afraid of syringes and needles.

A medical treatment

Always keep in mind that insulin is a medical treatment. There is no compromise allowed. You must inject your insulin at the prescribed moment, and it is your right to do so, regardless of your location.

You shouldn’t take the risk of having a hypoglycemia attack by injecting earlier at home or in the car before eating at a restaurant, for example.

A right

No law prohibits people with diabetes from injecting insulin or measuring their blood glucose (sugar) levels in a public place. Therefore, no one can prohibit you from doing so.

If, for example, a restaurant employee objects to your injecting at the table or forces you to do so in the washroom or outside the establishment, this is discrimination.

If you believe you’ve been a victim of discrimination, you can complain to the CDPDJ – the Commission des droits de la personne et des droits de la jeunesse (the Québec Human Rights and Youth Rights Commission). The CDPDJ has the power to protect the rights of people with diabetes and can investigate the situation.

Commission des droits de la personne et des droits de la jeunesse
Toll-free: 1 800 361-6477

 

Research and adaptation: Diabetes Québec Team of Health Care Professionals

November 2019

 

Adapted from:

Bergeron, Caroline, Dietitian (2013). “Courrier des lecteurs : L’injection d’insuline en public,” Plein Soleil, Diabetes Québec. p. 6.

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