Based on the favourable response to the recommendations for best practice in insulin injection technique given in 2012, the Forum for Injection Techniques (FIT), India has come up with the new provisions to cover the following areas in insulin technique: Counselling of geriatric persons with diabetes, injection in pregnancy, dermatological disease and surgical disease.
The new recommendations include:
Pre-injection counselling: Geriatrics
Counselling geriatric patients for self-injection can be a challenging task. Unlike their younger peers, they may have certain age related potential difficulty in executing the instructions for injections properly. Functional disability, depression and lack of self-motivation, impaired cognitive function, inflammatory arthropathy and motor system disorders can considerably affect the ability to administer insulin, monitor blood glucose and manage hypoglycaemia. Dexterity, visual impairment, hearing impairment are of utmost importance in this vulnerable group of patients.
Various guidelines for diabetes management in the elderly have discussed these points and suggested some practical remedial steps. It has been suggested that the physician should not use age as an excuse to avoid usage of insulin. Technical superiority of a product (analogue vs conventional) or an injection device (pen vs syringes), should be given due consideration. Along with insulin initiation, all elderly patients should be taught a structured self-monitoring and algorithm based insulin dose titration. Healthcare providers must ensure the involvement of responsible family members/attendants during the selection of insulin and explanation of injection technique, in case of frail and very old patients.
Pregnancy
Insulin is required in about 10-20 per cent of all antenatal women with diabetes, which complicates about one-sixth of all pregnancies. Patients should be reassured that insulin is not only safe in pregnancy, but also contributes to maternal and foetal well-being.
The abdomen is a safe site for insulin administration in pregnancy.
First trimester: Women should be reassured that no change in insulin site or technique is needed.
Second trimester: Lateral parts of the abdomen can be used to inject insulin, staying away from the skin overlying the foetus.
Third trimester: As mentioned in the FIT India guidelines, insulin can be injected over the abdomen while ensuring the skin fold is properly raised. Apprehensive patients may use the thigh or upper arm to inject themselves.
Dermatological disease
Insulin injection should be avoided at sites of active or recently healed infection or inflammations, such as skin and soft-tissues infections and psoriasis. Injection should not be administered in to keloids or scars. However, stable vitiligo is not a contraindication for insulin injection. Acanthosis nigricans is also not a contraindication. Insulin can be injected in to sites of lipoatrophy, but not lipohypertrophy.
Surgical disease
In patients with recent surgical wounds or open fistulas/ ileostomies/ colostomies, a different quadrant of the abdomen should be used for insulin injection. Adequate pre-injection cleansing must be done. Apprehensive patients with recent abdominal surgery may use the high or upper arm for injection.
EP News Bureau – Mumbai