|Year : 2014 | Volume
| Issue : 6 | Page : 800-803
Addendum 2: Forum for Injection Technique, India
Sanjay Kalra1, Yatan Pal Singh Balhara2, Manash P Baruah3, Manoj Chadha4, Hemraj B Chandalia5, Subhankar Chowdhury6, Jothydev Kesavadev7, KM Prasanna Kumar8, Sonal Modi9, Shailesh Pitale10, Shukla Rishi11, Rakesh Sahay12, Annamalai Sundaram13, Ambika G Unnikrishnan14, Subhash K Wangnoo15
1 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
2 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
3 Excel Center (Unit of Excel Care Hospitals), Guwahati, Assam, India
4 P.D. Hinduja Hospital and Research Centre, Mumbai, Maharashtra, India
5 Diabetes Endocrinology Nutrition Management and Research Centre, Mumbai, Maharashtra, India
6 IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
7 Jothydev's Diabetes and Research Center, JDC Junction, Mudavanmugal, Trivandrum, Kerala, India
8 Department of Endocrinology and Metabolism, M.S. Ramiah Medical College and Bangalore Diabetes Hospital, Bangalore, Karnataka, India
9 Department of Nutrition, Diabetes Endocrinology Nutrition Management and Research Centre, Mumbai, Maharashtra, India
10 Pitale Diabetes and Hormone Center, Nagpur, Maharashtra, India
11 Regency Hospital Private Ltd. and Centre for Diabetes and Endocrinology, Kanpur, Uttar Pradesh, India
12 Osmania Medical College, Hyderabad, Andhra Pradesh, India
13 Ambedkar Institute of Diabetes, Government Kilpauk Medical College, Kilpauk, Chennai, Tamil Nadu, India
14 Amrita Institute of Medical Sciences, Kochi, Kerala, India
15 Apollo Centre for Obesity, Diabetes and Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
|Date of Web Publication||20-Sep-2014|
Dr. Sanjay Kalra
Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The second addendum to the Forum for Injection Techniques (FIT), India recommendations, first published in 2012 and followed by an addendum in 2013, covers various important issues. It describes how the impact of the so-called non-modifiable factors, which influence the injection technique, can be modulated; provides fresh information on timing of glucagon-like peptide 1 receptor agonist injections, methods of minimizing pain during injections, amyloidosis, and factors that impact adherence to insulin therapy. The addendum also lists semantic changes made to keep the FIT recommendations updated.
Keywords: Degludec, exenatide, exenatide LAR, Glucagon like peptide-1 receptor agonists, liraglutide
|How to cite this article:|
Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, Chowdhury S, Kesavadev J, Prasanna Kumar K M, Modi S, Pitale S, Rishi S, Sahay R, Sundaram A, Unnikrishnan AG, Wangnoo SK. Addendum 2: Forum for Injection Technique, India. Indian J Endocr Metab 2014;18:800-3
|How to cite this URL:|
Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, Chowdhury S, Kesavadev J, Prasanna Kumar K M, Modi S, Pitale S, Rishi S, Sahay R, Sundaram A, Unnikrishnan AG, Wangnoo SK. Addendum 2: Forum for Injection Technique, India. Indian J Endocr Metab [serial online] 2014 [cited 2020 Dec 1];18:800-3. Available from: https://www.ijem.in/text.asp?2014/18/6/800/141344
| Introduction|| |
The Forum for Injection Technique (FIT), India, recommendations were published in 2012 as a guide to the science and art of insulin injection technique. These recommendations have enhanced awareness about the importance of appropriate insulin technique in insulin and diabetes therapy in India. The FIT India recommendations writing group also published an addendum in 2013, covering aspects of insulin technique, which had not received due coverage in the original document. At the same time, it was planned to review the original recommendations at regular, preferably yearly, intervals, to assess the need for further addenda.
With this mandate, a second addendum of the FIT India recommendations is being published this year. This addendum, as the previous one, should be read in conjunction with the original document. Apart from the additions related to injection - meal interval of glucagon-like peptide 1 receptor agonists, methods of minimizing pain during injections, amyloidosis, and factors that impact adherence were also added; the original manuscript has undergone extensive language editing. Important changes include substitution of the word 'compliance' with 'adherence' and of 'diabetics' with 'persons with diabetes', to reflect current semantics. Section 4.0 also highlights that the impact of so-called non-modifiable factors, which influence injection technique can be modulated, positively, by appropriate choice of modern insulin devices.
| Semantic Changes|| |
Certain substitutions have been made into the original FIT recommendations, 2012, to keep the document consonant with modern terminology.
These include the use of 'glucagon-like peptide-1 receptor agonists', 'adherence', and 'persons with diabetes', in place of the earlier terms: glucagon-like peptide-1 analogs, compliance, and diabetics.
Need for Indian guidelines
Several factors influence the success of insulin injection therapy, injection technique being one of them. However injection technique is highly variable and operator-dependent.
| Factors Influencing Injection Technique|| |
The factors that influence injection technique are classified in [Table 1].
There are some factors like dexterity, visual impairment, auditory impairment and learning skills, which cannot be modified, at least in the context of treatment initiation, where promptness plays a key role. These factors can be addressed, however, by choosing appropriate insulin devices, suited to the individual. For example, modern pens with magnified dose display, audible clicks to inform dose increments, and lower pressure requirements for plunging, can be helpful in differently-abled individuals. Guidelines are required to optimize the factors listed above [Table 6.13.1], and to ensure appropriate practice of insulin injection technique by both health care professionals and people with diabetes.
| Glucagon-Like Peptide-1 Receptor Agonists (Glp1ra)|| |
The frequency and timing in relation to meal may vary among the available GLP1RA. Exenatide is administered twice daily, 30 minutes before meals. Liraglutide is injected once daily, without regard to meal timings. Some physicians advise liraglutide at bed time to reduce gastrointestinal discomfort. Long-acting release (LAR) exenatide is injected with a thick gauge needle, once a week, at any time of the day.
| Correct Site Rotation|| |
Correct site rotation is defined as administering insulin injections at least 1 cm apart, in a systematic manner, to avoid repeated local tissue damage, while ensuring stable insulin absorption.
In a study to assess the frequency of LH and its relationship to site rotation, needle reuse, glucose variability, hypoglycemia and use of insulin on 430 outpatients injecting insulin, it was found that nearly two-thirds (64.4%) of patients had LH. There was a strong relationship between the presence of LH and non-rotation of sites, with correct rotation technique having the strongest protective value against LH [Table 2]. Of the patients who correctly rotated sites, only 5% had LH, while of the patients with LH, 98% either did not rotate sites or rotated incorrectly. Also, 39.1% of patients with LH had unexplained hypoglycemia and 49.1% had glycemic variability compared with only 5.9% and 6.5%, respectively, in those without LH. LH was also related to needle reuse, with risk increasing significantly when needles were used >5 times. 
Total daily insulin doses for patients with and without LH averaged 56 and 41 IU/day, respectively. This 15 IU difference equates to a total annual cost to the Spanish health care system of >122 million. 
According to this study, correct injection site rotation appeared to be the critical factor in preventing LH, associated with reduced glucose variability, hypoglycemia, insulin consumption and costs. 
| Amyloidosis|| |
Amyloidosis is a systemic or local disease in which amyloid substances are deposited extracellularly and impair tissue function.
It has been shown that local amyloid deposition very infrequently takes place at the site of repeated insulin injection in patients with insulin-requiring diabetes. ,,
The amyloid at the injected site was identified as amyloid insulin type (A-Ins). The nature of amyloid in the insulin injection site is considered to be insulin itself or insulin-related substance. ,,,,
Previously amyloid formation was suspected to be correlated with non-human insulin products, in particular those of porcine origin. However, there are newer cases where the use was limited to only human recombinant insulin or human insulin semi-synthetic analog, and therefore the species of insulin does not seem to be a major reason for the amyloidogenesis in insulin injected sites. 
Some of the reported cases were insulin resistant with elevated HbA1c levels.
Blood glucose control becomes markedly improved shortly after resection of the tumor or after the change of the injection site and the presence of the amyloid mass itself perhaps due to poor penetration of insulin, which may have contributed to the insulin resistance or in other words, refractoriness of insulin treatment.
The reported cases emphasize the necessity for the patient care staff to regularly check-up on the insulin injection site to prevent infection, inflammation or mass formation, and patient education for the alternate use of insulin injection site.
- Appropriate insulin regime
- Appropriate insulin dose
- Safety (no or minimal hypoglycemia)
- Tolerability (no weight gain)
- Flexibility (in timing of injection)
- Consistency (in action profile).
- Ease of use
- Ease of carrying
- Social acceptability
- Ease of maintenance.
The expert committee feels that the above updates are essential and are necessary to ensure appropriate practice of insulin injection technique by both health care professionals and people with diabetes. 
| References|| |
|1.||Blanco M, Hernández MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab 2013;39:445-53. |
|2.||Dische FE, Wernstedt C, Westermark GT, Westermark P, Pepys MB, Rennie JA, et al. Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient. Diabetologia 1988;31:158-61. |
|3.||Swift B. Examination of insulin injection sites: An unexpected finding of localized amyloidosis. Diabet Med 2002;19:881-2. |
|4.||Albert SG, Obadiah J, Parseghian SA, Yadira Hurley M, Mooradian AD. Severe insulin resistance associated with subcutaneous amyloid deposition. Diabetes Res Clin Pract 2007;75:374-6. |
|5.||Westermark P, Araki S, Benson MD, Cohen AS, Frangione B, Masters CL, et al. Nomenclature of amyloid fibril proteins. Report from the meeting of the International Nomenclature Committee on Amyloidosis, Part 1. Amyloid 1999;6:63-6. |
|6.||Westermark P, Benson MD, Buxbaum JN, Cohen AS, Frangione B, Ikeda S, et al. Amyloid fibril protein nomenclature. Amyloid 2002;9:197-200. |
|7.||Dische FE, Wernstedt C, Westermark GT, Westermark P, Pepys MB, Rennie JA, et al. Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient. Diabetologia 1988;31:158-61. |
|8.||Swift B. Examination of insulin injection sites: An unexpected finding of localized amyloidosis. Diabet Med 2002;19:881-2. |
|9.||Albert SG, Obadiah J, Parseghian SA, Yadira Hurley M, Mooradian AD. Severe insulin resistance associated with subcutaneous amyloid deposition. Diabetes Res Clin Pract 2007;75:374-6. |
|10.||Shikama Y, Kitazawa J, Yagihashi N, Uehara O, Murata Y, Yajima N, et al. Localized amyloidosis at the site of repeated insulin injection in a diabetic patient. Intern Med 2010;49:397-401. |
|11.||American Diabetes Association. Insulin administration. Diabetes Care 2004;27:S106-9. |
|12.||Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al.; International DAWN Advisory Panel. Resistance to insulin therapy among patients and providers: Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care 2005;28:2673-9. |
|13.||Brod M, Kongso JH, Lessard S, Christensen TL. Psychological insulin resistance: Patient beliefs and implication for diabetes management. Qual Life Res 2009;18:23-32. |
|14.||Brod M, Kongso JH, Lessard S, Christensen TL. Psychological insulin resistance: Patient beliefs and implication for diabetes management. Qual Life Res 2009;18:23-32. |
|15.||Bärtsch U, Comtesse C, Wetekam B. Injectable therapy pen devices for reatment of diabetes (article in German). Ther Umsch 2006;63:398-404. |
|16.||Saez-de Ibarra L, Gallego F. Factors related to lypohypertrophy in insulin treated Diabetic Patients; role of educational intervention. Pract Diabetes Int 1998;5;9-11. |
[Table 1], [Table 2], [Table 6.13.1]