Skip to main content
Top

27-11-2018 | Insulin | Article

Insulin Injection Technique Questionnaire: results of an international study comparing Brazil, Latin America and World data

Journal: Diabetology & Metabolic Syndrome

Authors: Luis Eduardo Calliari, Laura Cudizio, Balduino Tschiedel, Hermelinda C. Pedrosa, Rosangela Rea, Augusto Pimazoni-Netto, Laurence Hirsch, Kenneth Strauss

Publisher: BioMed Central

Abstract

Background

In 2014–2015, the largest international survey of insulin injection technique in patients with diabetes taking insulin was conducted in 42 countries, totaling 13,289 participants. In Brazil, patients from five public health centers were included. This study aims to evaluate insulin injection technique in Brazilian patients and compare results with Latin America (LatAm) and World data.

Methods

The insulin Injection Technique Questionnaire (ITQ) survey consisted of an initial patient section (questions applied by an experienced nurse), followed by observation of injection technique and examination of the injection sites by the health care professional.

Results

In Brazil, 255 patients were evaluated: 25% had type 1 diabetes mellitus (T1DM) and 75% had T2DM. In this study, 79% of patients injected less than 4 times a day, and 17.3% used insulin pens, compared to 28% in LatAm and 86% worldwide. Syringes were used by 78% of patients in Brazil, compared to 65% in LatAm and 10% globally. Differences in needle length were substantial—nearly 64% in Brazil inject with 8 mm length needle compared to 48% in LatAm and 27% worldwide. Additionally, 48% of patients in Brazil skip doses, 80% reuse pen needles and 57% reuse syringes with 27% having lipohypertrophy by exam.

Conclusion

Brazilian patients use syringes more and pens less, inject with larger needles and have more lipohypertrophy when compared to Latin America and World data. Their re-use of needles and syringes is also high. This study showed that in Brazil, teaching of proper injection technique has to be more widespread, and more intensive during diabetes educational sessions, and the type of delivered supplies must be updated to smaller, shorter needles preferred by patients, in order to facilitate adherence to treatment. From the ITQ, we conclude that there are many aspects of insulin injection technique that may be improved in Brazil.
Literature
1.
IDF DIABETES ATLAS. Eighth edition. 2017. http://​www.​diabetesatlas.​org. Accessed 17 Dec 2017.
2.
Viana LV, Leitão CB, Kramer CK, et al. Poor glycemic control in Brazilian patients with type 2 diabetes attending the public healthcare system: a cross-sectional study. BMJ Open. 2013;3:e003336. https://​doi.​org/​10.​1136/​bmjopen-2013-003336.CrossRefPubMedPubMedCentral
3.
Andrade CS, Ribeiro GS, Santos CAST, et al. Factors associated with high levels of glycated haemoglobin in patients with type 1 diabetes: a multicentre study in Brazil. BMJ Open. 2017;7(12):e018094. https://​doi.​org/​10.​1136/​bmjopen-2017-018094.CrossRefPubMedPubMedCentral
4.
Gomes MB, Cobas RA, Matheus AS, et al. Regional differences in clinical care among patients with type 1 diabetes in Brazil: Brazilian Type 1 Diabetes Study Group. Diabetol Metab Syndr. 2012;4(1):44. https://​doi.​org/​10.​1186/​1758-5996-4-44.CrossRefPubMedPubMedCentral
5.
Grassi G, Scuntero P, Trepiccioni R, et al. Optimizing insulin injection technique and its effect on blood glucose control. J Clin Transl Endocrinol. 2014;1(4):145–50. https://​doi.​org/​10.​1016/​j.​jcte.​2014.​07.​006.CrossRefPubMedPubMedCentral
6.
Campinos C, Le Floch JP, Petit C, et al. An effective intervention for diabetic lipohypertrophy: results of a randomized, controlled, prospective multicenter study in France. Diabetes Technol Ther. 2017;19(11):623–32. https://​doi.​org/​10.​1089/​dia.​2017.​0165.CrossRefPubMedPubMedCentral
7.
Guo XH, Ji LN, Lu JM, et al. Efficacy of structured education in patients with type 2 diabetes mellitus receiving insulin treatment. J Diabetes. 2014;6(4):290–7. https://​doi.​org/​10.​1111/​1753-0407.​12100.CrossRefPubMed
8.
Nakatani Y, Matsumura M, Monden T, et al. Improvement of glycemic control by re-education in insulin injection technique in patients with diabetes mellitus. Adv Ther. 2013;30(10):897–905. https://​doi.​org/​10.​1007/​s12325-013-0066-8.CrossRefPubMed
9.
Milech A, Angelucci AP, Golbert A, et al. Sociedade Brasileira de Diabetes. Práticas seguras para o preparo e aplicação de insulinas. Diretrizes da Sociedade Brasileira de Diabetes 2014–2015. http://​www.​diabetes.​org.​br/​profissionais/​images/​pdf/​diabetes-tipo-1/​002-Diretrizes-SBD-Aplicacao-Insulina-pg219.​pdf. Accessed 16 Feb 2018.
10.
Brown A, Steel JM, Duncan C, et al. An assessment of the adequacy of suspension of insulin in pen injectors. Diabet Med. 2004;21(6):604–8. https://​doi.​org/​10.​1111/​j.​1464-5491.​2004.​01206.​x.CrossRefPubMed
11.
Kaiser P, Maxeiner S, Weise A, et al. Assessment of the mixing efficiency of neutral protamine Hagedorn cartridges. J Diabetes Sci Technol. 2010;4(3):652–7. https://​doi.​org/​10.​1177/​1932296810004003​20.CrossRefPubMedPubMedCentral
12.
Frid AH, Hirsch LJ, Menchior AR, et al. Worldwide injection technique questionnaires study: population parameters and injection practices. Mayo Clin Proc. 2016;91(9):1212–23. https://​doi.​org/​10.​1016/​j.​mayocp.​2016.​06.​011.CrossRefPubMed
13.
Frid AH, Hirsch LJ, Menchior AR, et al. Worldwide injection technique questionnaire study: injecting complications and the role of the professional. Mayo Clin Proc. 2016;91(9):1224–30. https://​doi.​org/​10.​1016/​j.​mayocp.​2016.​06.​012.CrossRefPubMed
14.
Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91(9):1231–55. https://​doi.​org/​10.​1016/​j.​mayocp.​2016.​06.​010.CrossRefPubMed
15.
Vianna MS, Silva PAB, Nascimento CVD, Soares SM. Self-care competence in the administration of insulin in older people aged 70 or over. Rev Lat Am Enfermagem. 2017;30(25):e2943. https://​doi.​org/​10.​1590/​1518-8345.​2080.​2943.CrossRef
16.
Posicionamento Oficial SBD número 01/2017. Recomendações sobre o tratamento injetável do diabetes: insulinas e incretinas. http://​www.​diabetes.​org.​br/​profissionais/​publicacoes/​diretrizes-e-posicionamentos-1. Accessed 16 Feb 2018.
17.
Schwartz S, Hassman D, Shelmet J, et al. Multicenter, open-label, randomized, two-period crossover trial comparing glycemic control, satisfaction, and preference achieved with a 31 gauge × 6 mm needle versus a 29 gauge × 12.7 mm needle in obese patients with diabetes mellitus. Clin Ther. 2004;26(10):1663–78. https://​doi.​org/​10.​1016/​j.​clinthera.​2004.​10.​007.CrossRefPubMed
18.
Hirsch LJ, Gibney MA, Albanese J, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm × 32 G insulin pen needle in adults with diabetes. Curr Med Res Opin. 2010;26(6):1531–41. https://​doi.​org/​10.​1185/​03007995.​2010.​482499.CrossRefPubMed
19.
Bergenstal RM, Strock ES, Peremislov D, et al. Safety and efficacy of insulin therapy delivered via a 4mm pen needle in obese patients with diabetes. Mayo Clin Proc. 2015;90(3):329–38. https://​doi.​org/​10.​1016/​j.​mayocp.​2014.​12.​014.CrossRefPubMed
20.
Kreugel G, Keers JC, Kerstens MN, et al. Randomized trial on the influence of the length of two insulin pen needles on glycemic control and patient preference in obese patients with diabetes. Diabetes Technol Ther. 2011;13(7):737–41. https://​doi.​org/​10.​1089/​dia.​2011.​0010.CrossRefPubMedPubMedCentral
21.
Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86. https://​doi.​org/​10.​1056/​NEJM199309303291​401.CrossRef
22.
Blanco M, Hernández MT, Strauss KW, et al. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013;39(5):445–53. https://​doi.​org/​10.​1016/​j.​diabet.​2013.​05.​006.CrossRefPubMed
23.
Ji L, Sun Z, Li Q, et al. Lipohypertrophy in China: prevalence, risk factors, insulin consumption, and clinical impact. Diabetes Technol Ther. 2017;19(1):61–7. https://​doi.​org/​10.​1089/​dia.​2016.​0334.CrossRefPubMed
24.
Partanen T, Rissanen A. Insulin injection practices. Pract Diab Int. 2000;2000(17):252–4. https://​doi.​org/​10.​1002/​pdi.​91.CrossRef
25.
Hirsch L, Byron K, Gibney M. Intramuscular risk at insulin injection sites—measurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous insulin therapy. Diabetes Technol Ther. 2014;16(12):867–73. https://​doi.​org/​10.​1089/​dia.​2014.​0111.CrossRefPubMed
26.
BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Diabetes Mellitus. Brasília, 2006 (Cadernos de Atenção Básica, n. 16).
27.
Misnikova IV, Gubkina VA, Lakeeva TS, et al. A randomized controlled trial to assess the impact of properinsulin injection technique training on glycemic control. Diabetes Ther. 2017;8(6):1309–18. https://​doi.​org/​10.​1007/​s13300-017-0315-y.CrossRefPubMedPubMedCentral
28.
Cunha GHD, Barbosa RVA, Fontenele MSM, et al. Insulin therapy waste produced in the households of people with diabetes monitored in Primary Care. Rev Bras Enferm. 2017;70(3):618–25. https://​doi.​org/​10.​1590/​0034-7167-2016-0406.CrossRefPubMed
29.
Kalra S, Mithal A, Sahay R, et al. Indian injection technique study: population characteristics and injection practices. Diabetes Ther. 2017;8(3):637–57. https://​doi.​org/​10.​1007/​s13300-017-0243-x.CrossRefPubMedPubMedCentral
30.
Agencia Nacional de Saúde - downloaded from http://​www.​ans.​gov.​br/​perfil-do-setor/​dados-gerais. Accessed Feb 2018.

Be confident that your patient care is up to date

Medicine Matters is being incorporated into Springer Medicine, our new medical education platform. 

Alongside the news coverage and expert commentary you have come to expect from Medicine Matters diabetes, Springer Medicine's complimentary membership also provides access to articles from renowned journals and a broad range of Continuing Medical Education programs. Create your free account »