Why is correct insulin injection technique important?
Dear Colleagues,
This bulletin highlights the importance of correct insulin injection technique and summarises common problems associated with incorrect injection technique, and recommendations for preventing these.
For details on correct insulin injection technique, please refer the Chapter 3 in the LFAC & ISPAD (2017) Pocketbook for the Management of Diabetes in Childhood and Adolescence in under-resources countries, 2nd edition and follow the 8 steps under the heading ‘Giving an insulin injection with a syringe’. NOTE: Disinfection of skin prior to injection is not necessary unless hygiene is a real problem. Infection at injection sites is rare.
Incorrect injection technique has shown to cause variation in insulin absorption causing unexplained hypoglycaemia or hyperglycaemia, lipohypertrophy (accumulation of fatty lumps underneath the skin), pain, bruising, and bleeding. Bahendeka et al (2019) state in their recently published East Africa Diabetes Study Group (EADSG) guidelines that ‘the art of injecting insulin in still poorly understood in many health facilities’.
Lipohypertrophy is the most common problem caused by poor injection technique (FITTER, 2015). Blanco et al (2013) showed that 76.3% of patients with type 1 diabetes had lipohypertrophy, and Grassi et al (2014) found that visual inspection detected lipohypertrophy in 35.7% of patients and by palpation, in 45.8% with an overall detection of 48.7%. A recent ISPAD conference poster presentation from one of our LFAC supported centre in Ecuador found that 75% of 65 children and young adults with type 1 diabetes attending a camp had acquired Lipohypertrophy (Dos Santos et al, 2019). Injecting in lipohypertrophic tissue reduces insulin absorption and increases blood glucose level variability. This can lead to sub-optimal HbA1c, and may increase the amount of insulin needed or increase the risk of complications (FITTER, 2015; Grassi et al, 2014).
The table below lists the most common insulin injection problems and recommendations to prevent these. The recommendations are based on the ISPAD (Danne et al, 2018), FITTER (2015) and the recent East African Diabetes Study Group (EADSG) guidelines (Bahendeka et al, 2019).
Recommended injection sites (see picture below)
Abdomen (most reliable absorption rate, faster absorption that thighs, less affected by muscle activity or exercise); good for day time insulin
Thighs – front/outside of lateral aspect of thigh (the preferred site for slower absorption of longer acting insulins); faster absorption if muscle activity/exercise – recommended for night time insulin
Buttocks - lateral upper quadrant of the buttocks (the whole upper quadrant is useful)
The upper lateral aspect (outer arm) is an option but is difficult to self-inject and rotate and needs assistance from a parent, carer, or other third person
Important: DO NOT inject in medial (inside) part of arm due to risk of intramuscular injection (biceps muscle) and increased pain
Therapeutic Diabetes Education
EADSG guidelines (Bahendeka et al, 2019) recommend that Therapeutic Patient Education should be an integral part of teaching insulin injection therapy. Therapeutic education is a process where the competencies (knowledge, skills and attitudes) and the necessary support for self-control of a disease are provided to the patient and his/her family.
A practical educational tool has also been attached to this bulletin email to help you educate your patients on the correct rotation technique.
*FITTER provides the most up-to-date clinical evidence, analysis of the results of the largest injection technique study in the world and the ‘new’ international injection technique recommendations, delivered to the highest academic and scientific standards.
Blanco M, Hernández MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013 Oct;39(5):445-53
Dos Santos T, Salazar-González J, Werneck G, de Carvalho Pumputis F, Palacios J, Coll J, Lopez M, on behalf of the Fundación Diabetes Juvenil Ecuador (FDJE), 2019. Acquired lipohypertrophy among children and adolescents attending a diabetes camp. Poster presentation at the 45th International Society for Paediatric and Adolescent Diabetes (ISPAD) conference, 2019, Boston, USA
Life for a Child (LFAC) & International Society of Children and Adolescent Diabetes (ISPAD) 2017. Pocketbook for the Management of Diabetes in Childhood and Adolescence in under-resources countries. 2nd edition. Available from https://lfacinternational.org/education/guidelines/
