PHARMACOTHERAPY HOW TO INJECT INSULIN. Living your life as normal as possible.

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1 PHARMACOTHERAPY HOW TO INJECT INSULIN Living your life as normal as possible

2 In Germany about 1.9 million people with diabetes are being treated with insulin. For them, injecting insulin is part of their everyday life. Most of them had to overcome their initial fear of self-injection, but with some practice, the injection of insulin is almost painless. Imprecision and errors in handling and injecting insulin are often the cause for blood sugar fluctuations. Here we are giving you some tips that will make it easier for you to handle insulin. These instructions are not intended to replace the training given by your doctor or diabetes adviser, but are intended to complement or support a training course. TYPES OF INSULIN Insulins are grouped according to their origin and their length of action: 1. SHORT-ACTING INSULINS They cover the rise in blood glucose levels that occurs after eating and most of them should be injected at specific times before a meal. Human insulins (standard insulins): These insulins are identical to insulin made by the human pancreas and genetically manufactured with the help of bacteria or baker s yeasts. With most of them it is recommend to wait between injection and meal, since the action starts after minutes and lasts up to 6 hours. At times it may be necessary to eat a snack to prevent hypoglycaemia. Analogue insulins (insulin analogues): Similar to human insulin, but they have been slightly genetically altered. They will typically begin to work within minutes, but with a significantly shorter duration of action, up to a maximum of 4 hours. It is usually not necessary to wait between injection and meal and snacks are not usually needed and the blood sugar is easier to control. 2. LONG-ACTING INSULINS: Also called basal insulins or intermediate-acting insulins, they meet the body's basic insulin requirements, independent of meals: Long-acting insulins (or delayed-action insulin): These are human insulins with a substance added that prolongs their duration of action. For the standard neutral protamine Hagedorn (NPH) insulins these are usually proteins called protamines, which makes the solution cloudy. The duration of action is dosedependent, up to 12 hours. Long-acting insulins with protamine must be well mixed before insulin injection. These insulins are usually injected once or twice a day. Analogue insulins: These forms of insulin are genetically altered, giving them a duration of action of up to 24 hours and they only have to be injected once or twice a day. 3. MIXED INSULINS They contain a short-acting insulin, together with intermediate-acting insulin. They are available premixed in different combinations, for example, 30% short-acting and 70% intermediate-acting insulin. The amount of active insulin is measured as international units (IU) or just as units (U). In Germany insulin solutions are available in different concentrations. U-100 contains 100 units of insulin in 1 ml of solution. And U-200 contains 200 units of insulin in 1 ml of solution. Pens are usually filled with U-100 insulin. When using syringes, you must ensure to use the appropriate scaled syringe to safely prepare and administer 100-unit or 200-unit insulin, to prevent serious dosing errors.

3 THE RIGHT DOSE The amount of insulin needed varies from person to person. It may also vary for each person, depending on their overall state of health. When you are first starting insulin, it will take some time to find the right dose. Your diabetes team will help you adjust your dose over time. The amount of insulin a person needs depends on: Body weight Level of physical activity Constitution (the percentage of body fat and muscle mass) Diet Mental health (e. g. stress) Taking other medication Bacterial infections often require considerable dose adjustment When you first start using insulin, your diabetes team will discuss your treatment with you. It is important that you write down these directions in your diabetes diary so that you can refer to them later. You should also keep a record of the amount of units of insulin you are taking and of your blood sugar readings. Appropriate diabetes diaries can be ordered or downloaded at for example. It is normal for your insulin needs to change, if your circumstances change, such as when you get ill, with increased physical activity or when you change your job. When you notice that your blood sugar levels vary considerably, you should only adjust your insulin dose after you have talked to your diabetes team and were given appropriate instructions. They will give you specific advice on how to keep your blood sugar levels in a healthy range, by adjusting your meals or your insulin. Your diabetes team will create a plan for you, detailing what you should do if you forget to take your insulin.

4 CHOOSING THE RIGHT INJECTION SITE Insulin is injected into the subcutaneous fat, which is the fatty tissue just under the skin, from where it is slowly absorbed into the body. Fatty tissue is less highly perfused than muscle. The injection is therefore less painful and insulin is more slowly absorbed into the blood compared to an injection into a muscle. When you accidentally inject into the muscle, the insulin will get into your bloodstream more quickly and insulin levels rise faster than when administered into fatty tissue. This can lead to a rapid drop in blood sugar levels. The most suitable injections sites are abdomen, thighs and buttocks. These areas of the body are easy to reach and the risk of accidental injection into the muscle is low, as the layer of subcutaneous fat is sufficiently thick. The upper arm is usually no longer recommended as an injection site, due to the increased risk of accidentally injecting into the muscle. Front Back When selecting the injection site, consider the distribution of your subcutaneous tissue. If you are very slim, the thigh may not be a suitable injection site. If you are unsure, ask your diabetes team for advice. DIFFERENCES IN INSULIN ABSORPTION The rate of absorption and onset of action are different for each type of insulin, which you can further influence by your choice of injection site, as the rate of absorption of insulin into the bloodstream varies for each body area: Abdomen: Thigh: Buttocks / hips: fastest absorption slow absorption slowest absorption You can use this to your advantage, for example, if you want your insulin to act very fast or very slow: If you want to eat immediately after an injection, you should choose the abdomen as injection site.

5 The following table provides an overview of useful injection sites for different types of insulin: Type of insulin Injection site Action Long-acting insulins Thigh / buttocks Insulin is absorbed more slowly, lasts longer Short-acting insulins / insulin analogues / meals / correction insulin Mixed insulins Abdomen In the morning: Abdomen Rapid insulin absorption Rapid effect of the shortacting part that covers breakfast In the evening: Thigh Slower absorption to last through the night Other ways that speed insulin absorption: If you engage in physical activity after the injection, such as exercising, insulin enters the bloodstream more quickly. Temperature: Heat from a sauna or sunbathing; a hot bath, a hot shower or even a hot water bottle can double the speed of insulin absorption. Massaging the injection site will increase the absorption of insulin into the bloodstream. Always keep in mind: Faster absorption of insulin may result in hypoglycaemia! Increasing your insulin units not only has a stronger effect, but the effects will also last longer than with fewer units. USING THE RIGHT TECHNIQUE The way you inject your insulin is crucial for its effect, whether you use an insulin pen or a syringe. Cloudy insulin must be mixed be mixed thoroughly before it is injected, otherwise more diluent than insulin is injected. To do this, gently move the pen up and down times or roll it between your hands times before injection. Use your thumb, index finger or middle finger to make a skin fold, so you only raise fatty tissue and do not pull up any muscle. Hold the needle vertically or at a 45-degree angle, depending on the length of the needle and the thickness of the skin fold. Avoid the injection going too deep into the tissue. Before each injection always check if your pen is working properly, by holding the pen with the needle pointed upwards and squeezing 1-2 IU of insulin upwards until a drop of insulin appears at the tip of the needle. Slowly inject the insulin, while holding the skin fold. Leave the needle in the skin for a good 10 seconds after the insulin has been injected to prevent insulin from leaking out. Learning how to inject safely requires training and practice. Your diabetes team will show you the correct techniques.

6 ROTATING YOUR INJECTION SITES You may have a preferred area for your injections, such as the abdomen, but it is important to regularly change (rotate) your injection sites. Frequently injecting in the same place can cause hard lumps and fatty tissue to accumulate, and the site will become less sensitive to pain. This is called lipohypertrophy. Even though these sites often become favourite injection sites because injections are less painful, the abnormal tissue accumulation can hinder the rapid onset and uniform insulin absorption. This may result in severe fluctuations in blood sugar and a fluctuating, often increased need for insulin. If you notice localised accumulations of fat or lumps at these injection sites, avoid them for a few months, until your skin is back to normal. Rotate your injection sites on the abdomen or thighs in horizontal and vertical direction, with the injections being at least 2-3 cm apart. You should also use the abdominal flanks for your injections. Do not inject into scar tissue, as this may also change absorption of your insulin. HOW TO STORE INSULIN Insulin must be stored properly to ensure it remains effective. You can keep insulin vials that you're currently using at room temperature for up to 6 weeks. Store your insulin away direct sunlight, extreme heat or extreme cold. Never leave your insulin in the glove compartment of a hot car or out in direct sunlight. Store spare insulin in the vegetable compartment of your fridge or a cool room in the basement. Never store insulin in the freezer, and never use frozen insulin. Never vigorously shake your insulin, this could lead to clumps or crystallisation. To mix cloudy long-acting insulin, gently roll it between your hands or turn it up and down times, making sure that there are no air bubbles or foam in the solution. HOW TO DISPOSE OF NEEDLES AND SYRINGES SAFELY Pen needles should be changed after each injection. More frequent use will lead to blunting of the needle tip and painful injuries of the skin. Used needles or syringes must not be flushed down the toilet, and extra precautions should be used when disposing of them in the normal household waste, and they should never be left lying around. Proper disposal of used materials protects others from harm and injuries and prevents needles from being used twice. Your diabetes team will tell you how to safely dispose of your needles. You can also consult your pharmacist, who may dispose of your used needles for you. SUMMARY Your diabetes team will teach you how to handle insulin. They will tell you when and how to inject insulin properly to achieve the best effect. It is important that you always read and follow the instructions on your insulin bottles, vials, or preloaded pens. Should you have any questions, do not hesitate to ask your doctor, your diabetes adviser or your pharmacist. For more information on diabetes and insulin therapy visit our website In combination with a healthy diet, exercise and correct self-monitoring of blood glucose levels, your insulin treatment will help you to lower your blood sugar, reduce the risk for complications and live your life as normal as possible.

7 SOURCES Schmeisl, Gerhard-W. Schulungsbuch für Diabetiker. Elsevier GmbH, Munich, 7th Edition 2011: Hien, P. & Böhm, B. Diabetes Handbuch. Eine Anleitung für Klinik und Praxis. Springer Medizin Verlag, Heidelberg, 6th Edition 2010: 135 and Copyright 2013, Eli Lilly and Company. All rights reserved. DEDBT01951