FIT UK Recommendations For Injection Technique

DIABETES CARE IN THE UK
FIT UK Forum
for Injection
Technique UK
The UK Injection
and Infusion
Technique
Recommendations
4th Edition
Optimising
Diabetes Care
UK Injection and Infusion Technique Recommendations
Preface
The Forum for Injection Technique (FIT) UK provides

evidence-based best practice recommendations for people
with diabetes who are using injectable therapies and for
clinicians who care for people with diabetes using injectable
therapies. Through these recommendations, people with
diabetes can achieve the best possible health outcomes by
ensuring that the correct dose of medication is delivered
to the correct injection site, using the correct technique.
FIT UK understands that written guidelines alone will not
change clinical practice unless appropriately implemented.
FIT UK is committed to engaging in a range of initiatives
including research, education and support for healthcare
professionals (HCPs) carers and people with diabetes.
Our Objectives
To review the injection and infusion techniques currently
being used by people with diabetes
To identify, and provide information on Best Practice and

education programmes available in the UK
To raise awareness of the impact that existing and emerging

research regarding injection technique may have on health
outcomes and wellbeing for those with diabetes who require
subcutaneous injection therapy
To facilitate opportunities, in which best practice can be

discussed, developed, implemented and evaluated across
the UK
3
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
Over 16 years ago a small pioneering group of

medical and nursing professionals gathered for
the first time to explore the evidence for optimal
injection technique.
FIT UK was established following the 3rd International Injection Technique

meeting in Athens 2009. Informed by the results of the International
Injection Technique Survey (1) and contemporaneous injection technique
evidence from around the world, the diabetes specialist nurses, founders
of FIT UK were determined to share their findings and their passion for
optimal injection technique not only in the UK but around the world.
FIT UK has grown from a single entity based in the UK and is now
represented in countries including:
Africa
Canada
India
Europe
Latin America
Middle East
Pacific Rim including
--Australia and New Zealand
--China
--Japan
--Korea
--Malaysia
--Philippines
--Singapore
Diabetes UK estimates that more than one in sixteen people in the UK

have diabetes (diagnosed or undiagnosed) and that there are four million
people living with diabetes in the UK. This figure is projected to rise to five
million people by 2025. (2)
Diabetes diagnosis rates are equivalent to:

Around seven hundred people every day (2)
Thirty people every hour (2)
One person every two minutes (2)
4 DATE PUBLISHED: October 2016

FIT UK
Everyone with Type1 Diabetes Mellitus (T1DM) will need insulin from
diagnosis (3). Currently there are 400,000 people in the UK with T1DM
and over 29,000 of them are children. The number of people diagnosed is
increasing by 4 percent every year and most commonly in children under
five years old. (4)
New and emerging evidence shows that optimal injection technique is

critical to improving health outcomes. A pioneering study by Blanco (5)
demonstrated that almost two thirds of patients have lipohypertrophy
due primarily to incorrect or no rotation of injection sites. Of the patients
with lipohypertrophy 39.1% had unexplained hypoglycaemia and 49.1%
had glycaemic variation. Patients with lipohypertrophy were found to
be using much more insulin than those without, estimated to cost the
Spanish Healthcare system 122million Euros per year in excess insulin
usage.
A study by Grassi (6) demonstrated that a multimodal approach to

injection technique education and support could reduce glycated
haemoglobin (HbA1c) by 6 mmol/mol (0.58%) in patients treated with
insulin. Interestingly this was achieved using less insulin and without
any weight gain. The development of FIT UK and the subsequent UK
Injection and Infusion Technique Recommendations 4th Edition have been
supported by BD Europe. They have also been endorsed by Diabetes
UK along with the pharmaceutical companies whose therapies include
subcutaneous injections of insulin and glucagon-like peptide-1 receptor
agonists (GLP-1 receptor agonists).
5
FIT UKs overarching mission is:
To support people with diabetes using injectable

therapies to achieve the best possible health
outcomes that are influenced by correct injection
technique.
To date FIT UK has delivered many education programmes and produced
the First UK Injection Technique Recommendations (2010) and Safety
Recommendations (2012) which have been distributed and accessed
online by many thousands of health care professionals. FIT UK has also
produced a range of educational support materials and
e-learning modules.
FIT UK is committed to supporting the implementation of the

recommendations and developing them further as new evidence emerges.
We welcome any comments, suggestions and active participation in
ensuring that the updated recommendations remain relevant and useful
for now and in the future.
web: www.fit4diabetes.com
email: infouk@fit4diabetes.com

Contents
Preface and Objectives 3

Introduction 4
FIT UK 5
Endorsements 8
KEY 10
1.0 Psychological Challenges of Injections 11

2.0 Therapeutic Education 15
3.0 Injection Process 16
4.0 Injectable Therapies 22
5.0 Lipohypertrophy 23
6.0 Injection Issues 26
7.0 Pregnancy 27
8.0 Technology 28
9.0 Safety 30
10.0 Golden Rules 33
References 39
Contributors 46
Abbreviations 47
Endorsements
Diabetes UK both welcomes and supports the FIT initiative.

Good injection technique leads to good blood glucose control which is vital in preventing the long
term complications of diabetes. As so many people with diabetes are now being prescribed injectable
medication, this is a timely and important enterprise which will bring great
benefit to them.
Simon ONeill, Director of Health Intelligence. DIABETES UK
Advances in the treatment of diabetes have led to an increase in the number of injectable therapies
available. Correct technique is of paramount importance in order to ensure the benefits of injectable
therapies such as insulin and GLP-1s. The Forum for Injectable Therapy (FIT) provides comprehensive
evidenced based guidelines to improve the process and education of self-injection technique for
people with diabetes. As a company committed to improving the care of patients with diabetes, Lilly
UK welcomes the FIT initiative as an important step in supporting diabetes care in the
United Kingdom.
Ian Dane, Senior Director, Eli Lilly & Company
Novo Nordisk fully endorse the FIT initiative. The benefits of modern injectable medications for the
treatment of diabetes can only be fully realised through the use of correct injection technique. Novo
Nordisk believes it is imperative that Healthcare Professionals understand the importance of good
injection technique and convey this to people with diabetes under their care. FIT
is a superb initiative, from leading professionals in the diabetes care, which will
make a big difference in this area.
Kirsty Tait, Diabetes Marketing Director, Novo Nordisk Ltd.

FIT UK
BD Medical Diabetes Care
Sanofi are a company who strive to improve the care for people with diabetes who are using insulin
and GLP-1 therapy by providing a range of injectables. We are proud to support the FIT (Forum for
Injection Technique) initiative which is aiming to improve current practice through demonstration
of best practice and the sharing of scientific evidence. We, too, appreciate the importance of good
injection technique in ensuring people with diabetes who are using injectable therapy
achieve the most benefit from their medication and wish FIT every success. We look
forward to working with FIT in the future.
Sanofi Nicky Barry, Divisional Director Diabetes,
AstraZeneca are pleased to support the FIT initiative. We are striving to provide medicines which can
provide better outcomes for people with Type 2 Diabetes but this can only be achieved when they are
used correctly. Adoption of the FIT guidelines in clinical practice will
help ensure that the best outcome is obtained from all injectable
medicines.
Jay Ark, Head of Injectable at Diabetes Marketing, AstraZeneca
Becton Dickinson has been supporting the ground breaking and inspirational work of the Forum for
Injection Technique for over 8 years. The new 4th Edition of The UK Injection and Infusion Technique
Recommendations follows the Worldwide FITTER Congress held recently in Rome 2015. During this
worldwide event which included 183 participants from 54 countries, delegates reviewed results data
from a worldwide injection technique survey, and this wealth of new data provided the evidence to
help formulate the best practice recommendations you will find in this UK 4th Edition.
Our BD mission; Improving the quality of daily life for people with diabetes, through access to
innovative solutions is incredibly important to all who work at BD, and BD is proud to endorse the
dedicated expert work that FIT UK undertakes. BD welcomes the publication of the 4th Edition of The
UK Injection and Infusion Technique Recommendations and commends the FIT Board
and all the dedicated clinicians from all over the UK for their great achievement.
Loc Herve, Business Unit Director Diabetes Care BD
9
KEY
A Scientific Advisory Board (SAB) (Athens 2009) led the review of available
evidence and decided that for the strength of a recommendation the
following scale would be used:
A STRONGLY RECOMMENDED
B RECOMMENDED
C UNRESOLVED ISSUE
For the scientific support the following scale was used.

At
1 least one randomised controlled study.
At least one non-randomised (or non-controlled or epidemiologic) study.
2
Consensus
3 expert opinion based on extensive patient experience.
A number of significant studies have been published in the intervening years since 2009. Therefore FITTER has
conducted a further review of critical evidence and included this within the 4th Edition of the New Injection
and Infusion Recommendations. The body of evidence has been subjected to the rigour of the strength scale of
recommendations as above however with a slightly modified KEY for the scientific support:
For the scientific support the following modified scale was used.
1 At least one rigorously performed study, peer-reviewed and published.
2 At least one observational, epidemiologic or population-based study.
3 Consensus expert opinion based on extensive patient experience.
Thus each recommendation is followed by both a letter and number (i.e. A2). The letter indicates the weight a
recommendation should have in daily practice and the number, its degree of support in the medical literature. The
most relevant publications bearing on a recommendation are also cited. There are few randomised clinical trials
in the field of injection technique (compared, for example, with blood pressure control) so judgements such as
strongly recommended versus recommended are based on a combination of the weight of clinical evidence, the
implications for patient therapy and the judgement of the group of experts.
These recommendations apply to the majority of people with diabetes using injectable therapy, but there will
inevitably be individual exceptions for which these recommendations must be adjusted.
Acknowledgment
The New Insulin Injection and Infusion Recommendations for Patients with Diabetes: Frid AH, Kreugel G, Grassi
G, et al. New insulin delivery recommendations. Mayo Clin Proc. September 2016;91(9):1231-1255. informed these
recommendations and we thank the editors of the Mayo Clinic for permission to use material from this article.

STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one rigorously performed study,

peer-reviewed and published
At least one observational, epidemiologic
or population-based study.
Consensus expert opinion based on
extensive patient experience.
1.0
Psychological Challenges
of Injections
1.1 Emotional and

Psychosocial Issues 4 With all patients it is important 6 All patients should be supported
to explain that insulin is not a to self-manage as much as
1 Show empathy by addressing punishment or failure. Insulin possible and be involved in
the patients emotional when used correctly is the most designing their regimen to
concerns first. The healthcare effective treatment we have for fit their lifestyle. This could
professional (HCP) should managing blood glucose. For include basal bolus therapy,
explore worries and barriers patients with Type 1 Diabetes carbohydrate counting, using
to treatment and acknowledge Mellitus (T1DM) it is the primary insulin pens and insulin pumps.
that anxiety is normal when treatment and for patients with
beginning any new medication, Type 2 Diabetes Mellitus (T2DM),
especially injection therapy. it may be used in addition to oral
(7,8,9,10,11,12,13,14,15,16,17,18) therapy but may also be used in
combination with GLP-1 receptor
agonists to improve blood
2 People, with diabetes should glucose control. For patients
be encouraged to express with T2DM it is important
their feelings about injecting, they understand the natural
particularly their fears; progression of the condition and
frustration, anger and struggles. that insulin therapy is a part of
the logical progression in its
management. (19,20,7)
3 Patients of all ages should be
reassured that this is a learning 5 Inform patients that improving
process and the health care their blood glucose levels
team is there to help along the may make them feel better in
way. The message is: you are the long term. Many patients
not alone, we are here to help report an overall improvement
you; we will be supporting you in their health and well-being
until you are comfortable and when taking insulin. Managing
confident giving yourself an blood glucose levels with insulin
injection. helps to prevent long-term
complications. (8,21)
11
1.0
of Injections
1.2 Strategies for Reducing 7 If bleeding or bruising occur, 10 Fear and anxiety can be
Fear, Pain, and Anxiety assess and reassure the significantly reduced by having
patient that these do not affect the person (parent and child)
1 Include caregivers and family the absorption of insulin or give themselves a dry injection.
members in the planning and overall blood glucose control.
education of the person who is If bruising continues or 11 Most are surprised at how
injecting where appropriate and haematomas develop, observe relatively painless the injection
agreed by the individual. the injection technique and is.
suggest improvements (e.g.
2 Tailor the therapeutic regimen correct rotation of injection 12 On rare occasions the use
to the individual needs of the sites). of injection ports may help
patient. reduce fear of injections and
8 Children have a lower threshold associated pain. Fig 1
3 Have a compassionate and clear for pain. The HCP should ask (24) (25) (11) (26) (27)
approach when teaching correct about pain. (9) (22) For young
injection technique. children consider distraction
techniques or play therapy (e.g.
4 Demonstrate the correct injecting the childs own soft toy
injection technique to the or doll). Older children respond
individual and assess their better to cognitive behavioural
ability to self-inject. therapies (CBT). (7) (10) (23)
5 In the case of fear provoked by

seeing needles consider the 9 CBT includes relaxation training,
use of devices which hide the guided imagery, graded
needle. exposure, active behavioural
rehearsal, modelling and
6 Consider the use of vibration, positive reinforcement as well
cold temperature or pressure to as appropriate rewards. (23)
suppress pain during injection.
(254)
With kind permission. i-Port Advance injection port is a registered trademark. 2016
Medtronic MiniMed, Inc. All Rights Reserved. Figure 1: Medtronic Port in situ.

RECOMMENDED
UNRESOLVED ISSUE

1.0
of Injections
13 Insulin pens with very 1.3 Tips for Injection 5 Insert the needle through the
short needles may be more Education skin in a smooth but not jabbing
acceptable to patients than the movement. Pain fibres are in
syringe and vial. This should be 1 Demonstrate the correct the skin and going through the
discussed with the person (and injection technique to the skin too slowly or too forcefully
family) when teaching injection person (and family.) Then may increase the pain. (31)
technique. The 4 mm pen ask the patient (and family)
needle is reported by patients to demonstrate the correct
to be less painful than longer technique. 6 Inject the insulin slowly
needles. (8,28,29,30) ensuring that the plunger
2 Advise that insulin in use is (syringe) or thumb button (pen)
14 If patients occasionally kept at room temperature to has been fully depressed and
experience sharp pain on make for a more comfortable all insulin has been injected.
injection they should be injection. Cold insulin often With pens the patient should
reassured that the needle may produces more pain. count to 10 after the button has
have touched a nerve ending been fully depressed before
which happens randomly and 3 Advise that the skin should be withdrawing the needle.
will not cause any damage. clean and dry before injecting.
Patients do not need to use 7 Use a sterile, new needle for
a disinfectant (e.g. alcohol each injection. (5,32,33,34,35,
15 If pain persists the HCP should swab) on the skin, but if they 36,37,38,39,40,41,42,43)
see the patient and evaluate do, they should allow it to dry
their injection technique. completely before injecting. 8 HCPs should teach the
importance of rotation and
agree a rotation pattern with
4 Use needles of the shortest the patient when initiating
length (4mm), smallest injection therapy. (5)
diameter (highest gauge
number), and the tip with the 9 Insulin will not be well-
lowest penetration force to absorbed if it is always injected
minimize pain. (31) into the same area. (5) (44)
13
1.0
of Injections
10 It is important to move 14 Insulin pens, pen cartridges
injections at least 1 cm (half an and vials should not be
inch) away from the previous shared in order to prevent the
injection. (5) transmission of infectious
diseases. (32,33,47,34,35,36,
11 Use all injection sites 37,38,39,40,41,42,43)
appropriate to the patients
preference on the body
including the back of the arms,
buttocks, thighs and abdomen.
(5)
12 If the same injection site is used

repeatedly lipohypertrophy
may develop (lumpy, firm and
enlarged tissue). The insulin
will not be absorbed correctly
if injected into these areas.
(5,45,46)
13 If pain is experienced when

injecting large volumes of
insulin the dose may need to
be divided into two injections
of a smaller volume or the
concentration of insulin may
need to be increased.

RECOMMENDED
UNRESOLVED ISSUE

2.0
Therapeutic
Education
2.1 Educational Content optimal needle lengths 2.2 Role of the Health Care
Safe disposal of used sharps Professional
1 The HCP should spend time
hypoglycaemia,
exploring patient (and other 1 Teach patients (and other
where appropriate
care-givers) anxieties and care-givers) how to inject
(19,20,21,28,48,49,50,51)
barriers to the injecting process correctly and addressing the
and insulin itself. (48,19) many psychological hurdles the
4 Instructions should be given in patient may face when injecting
2 At the beginning of injection or infusing, especially at the
both verbal and written form,
therapy the HCP should discuss initiation of treatment. (50,48)
individually tailored to the
each of the essential topics and
needs of the person.
ensure this information has
been fully understood, and this 2 Is to understand the anatomy
5 Level of knowledge should
should be assessed at least of insulin delivery sites in
be assessed and observed,
every year thereafter. (12) order to help patients avoid
and all aspects of injection
technique including injection intramuscular (IM) injections
3 The essential injection or infusions and ensure that
sites inspected and palpated,
technique topics include: injections and infusions are
if possible at each visit but at
the injectable therapy consistently given into the
least every year. This should
regimen subcutaneous (SC) tissue,
be documented in the patients
the choice and management without leakage/backflow
records. (48,49,51)
of the devices including or other complications.
safety devices (52,53,54,55,56)
the choice, care and self-
examination of injection 3 Is to have knowledge of the
sites time action profile of the
correct injection techniques different types of insulin
(including site rotation, and GLP-1 receptor agonists
injection angle and possible and the absorption profiles
use of lifted skin folds) from different injection sites.
Resuspension of insulin (57,58,59,60)
where appropriate
injection complications and
how to avoid them
15
3.0
Injecting Process
3.1 Injection Site Care 5 Patients should not inject

through clothing. (64)
1 The site should be inspected by

the patient prior to injection.
Injections should then be given
in a clean site using clean
hands. Fig 2 (61,62,63)
2 Soiled skin should be cleaned

according to basic common
standards with soap and water.
If alcohol is used to clean the
site, the skin must be allowed
to dry completely before the
injection is administered. Fig 3
(64,65)
3 Disinfection of the site is

usually not required although
local decisions may be taken in
a clinical setting to do so. Figure 2:
Recommended injection sites.
(32,66,67,68,69)
4 Patients should never

inject into sites of
lipohypertrophy, inflammation,
oedema,ulceration or infection,
nodules, scar tissue, tattoos,
hernias and stomas. (70,52,
71,72,73,(74,75,76,77,78)
Figure 3: Check the injection site. Ensure both

the injection site and the injectors hands are
clean prior to injecting.

RECOMMENDED
UNRESOLVED ISSUE

3.0
Injecting Process
3.2 Re-suspension of Cloudy 5 Store unopened insulin in a

refrigerator where freezing
Insulin
is unlikely to occur, as per
1 Cloudy insulins (e.g. NPH and manufacturers instructions.
pre-mixed insulins) must be (87,88)
gently rolled and inverted ten
times each but not shaken 6 After initial use, insulin (in pen,
until the crystals go back into cartridge or vial) should be
suspension and the solution stored at room temperature for
becomes milky white. up to 30 days or according to
Fig 4 and Fig 5 manufactures recommendations
x10
(79,80,81,82,83,84) and within expiry date. Pre-
mixed insulin pens and some of
2 Invert the pen or vial and roll (a the newer insulins may vary
full rotation cycle between the check individual manufacturers
palms). Inversion and/or rolling recommendations. (89,90)
should be performed a total of
20 times immediately before
every injection with cloudy 7 Storage of Insulin
insulin. Insulin IN USE should be stored
below thirty degrees Celcius but
Figure 4: Re-suspension of cloudy insulin
3 Visually confirm that the re- do not refridgerate however,
suspended insulin is sufficiently Insulin NOT IN USE should be
mixed after each rolling and stored in a refridgerator (two to
inversion, and repeat the eight degrees Celcius), do not
procedure if crystal mass freeze, do not expose to direct x10
remains in the cartridge. sunlight. It should be allowed
(82,83,85,86) to warm up for approximately
fifteen minutes prior to use for
4 Vigorous shaking should be the first time. (87,88)
avoided since this produces
bubbles which reduce accurate
dosing.(82,83,85)
Figure 5: Re-suspension of cloudy insulin
17
3.0
Injecting Process
3.3 Needle Length 2 The 4 mm pen needle may be Others may inject using the 4
used safely and effectively in mm needle without lifting a skin
1 The 4mm pen needle inserted
all obese patients. Although fold. (58,100,105,103)
perpendicularly (at ninety
it is the needle of choice
degrees) is long enough to
for these patients, a 5mm 5 When any syringe needle is
penetrate the skin and enter
needle may be acceptable. used in children, adolescents
01
the subcutaneous tissue, with

(96,97,98,99,100,101,102) or slim to normal weight
2
little risk of intramuscular

01
01
adults (BMI 19-25), injections

2
2
(or intradermal) injection.

should always be administered
Therefore it should be
3 The 4 mm pen needle should into a lifted skin fold.
considered the safest pen
be inserted perpendicular (at (57,58,53,106,93,100,101,
needle for adults and children
ninety degrees) to the skin 102,105,94,56,103,104,107,108,
regardless of age, gender
surface and not at an angle, 109,110,111,112,113,114,115,116,
and Body Mass Index (BMI).
regardless of whether a skin 117,118,119,120,121,122,123,124,
(9,92,93,94,95)
fold is raised. Fig 6 (103,104) 125,126,127,128,129,130,131)
Longer pen needles increase

the chance of injecting into the 4 Very young children (6-years 6 Use of syringe needles in very
muscle, therefore it is crucial old and under) and extremely young children (less than
to perfect the technique for thin adults (BMI<19) should use 6 years old) and extremely
the needle you are using or the 4mm needle by lifting a skin thin adults (BMI <19) is
switch to short pen needles. fold and inserting the needle not recommended, even if
perpendicularly into it. they use a raised skin fold,
because of the excessively
high risk of intramuscular (IM)
injections. (57,58,53,106,93,
100,101,102,105,94,56,103,
104,107,108,109,110,111,112,
Skin layer - don't inject here
113,114,115,116,117,118,119,
Subcutaneous layer - inject here 120,121,122,123,124,125,126,
127,128,129,130,131)
Muscle layer - dont inject here
Figure 6: Intramuscular injection (IM)

RECOMMENDED
UNRESOLVED ISSUE

3.0
Injecting Process
7 Children still using the 5mm 3.4 Lifting a Skin Fold 3 The optimal sequence should
pen needle should inject using be:
1 Each injection site should
a lifted skin fold. But children Lift a skin fold;
be examined individually
using pen needles 5mm Inject insulin slowly at ninety
and a decision made as to
should be changed to 4 mm pen degrees to the surface of the
whether lifting a skin fold is
needles if possible; and if not, skin fold;
required, taking into account
should always use a lifted skin Leave the needle in the skin
the needle length used. The
fold. (58,100,105,103) for a count of 10 after the
recommendation should be
plunger is fully depressed
provided to the patient in
8 If arms are used for injections (when injecting with a pen);
writing and documented in their
with needles 6mm long, a Withdraw needle from the
care plan.
skinfold must be lifted, which skin at the same angle it was
requires injection by a third inserted;
2 The lifted skin fold should not
party. (103) Release skin fold;
be squeezed so tightly that it
Dispose of used needle
causes skin blanching or pain.
9 Avoid indenting the skin by safely.
Fig 7
excessive pressure during
injection, as the needle may
penetrate deeper than intended
and enter the muscle.
10 Health care authorities and

payers should be alerted to
the risks associated with using
syringe or pen needles 6mm in
children. (35,106,110)
Figure 7: Correct (left) and incorrect (right) ways of performing the skin fold.
19
3.0
Injecting Process
3.5 Needle Reuse 3.6 Rotation of Injecting Sites 3 Patients should be taught an
easy-to-follow rotation scheme
1 Syringe or pen needles should 1 Injections should be
from the onset of injection
only be used once. Reusing systematically rotated in such
therapy. This may be adjusted
insulin needles is not optimal a way that they are spaced at
as needed while therapy
injection practice and patients least 1cm from each other in
progresses. The HCP should
should be discouraged from order to avoid repeat tissue
review the site rotation scheme
doing so. trauma. Fig 9 (90,136,47,137)
with the patient at least once a
Fig 8 (1,68,78,132,133,134)
year. (139,140,141,44,142,143,
144,145)
2 One scheme with proven
2 There is an association between effectiveness involves dividing
needle reuse and the presence the injection site into quadrants
of lipohypertrophy, although using one per week and
a causal relationship has moving quadrant to quadrant
not been proven. Patients in a consistent direction (e.g.
should be made aware of clockwise). Fig 10 (138)
this association (and also the
association between reuse and
pain or bleeding). (68,70,135)
BEFORE AFTER
Figure 8: Damage to needle if reused. Figure 9: Injections within any quadrant should Figure 10: Sample structured rotation plan for
x370 magnification. be spaced at least 1cm from each other. abdomen and thighs. Divide the injection area
into quadrants or zones. Use 1 zone per week
and move clockwise.

RECOMMENDED
UNRESOLVED ISSUE

3.0
Injecting Process
3.7 Correct Use of Pens 4 Pen needles should 3.8 Correct Use of Syringes
be used only once.
1 Pens should be primed 1 When drawing up insulin from
(62,63,68,106,151,152,153,154)
(observing at least a drop at an insulin vial, the air equivalent
the needle tip) according to the to the dose (or slightly greater)
manufacturers instructions should be drawn up first and
5 The thumb button should only
before the injection in order to injected into the vial to facilitate
be touched once the pen needle
ensure there is unobstructed insulin withdrawal. Ensure that
is fully inserted. After that the
flow and to clear needle dead the syringe to be used is an
button should be pressed along
space. Once flow is verified, the INSULIN syringe. Use of any
the axis of the pen, not at an
desired dose should be dialled other type of syringe can cause
angle. (155)
and the injection administered. serious harm. All regular and
(29,146) single insulin (bolus) doses are
6 After pushing the thumb button
measured and administered
completely in, patients should
2 Pens and cartridges are for a using an insulin syringe or
count slowly to 10 before
single patient and should never commercial insulin pen device.
withdrawing the needle in order
be shared between patients due Intravenous syringes must
to get the full dose and prevent
to the risk of biological material never be used for insulin
the leakage of medication.
from one patient being drawn administrationRRR 2010.
(79,33,147,149,156,157)
into the cartridge and then (253)
injected into another person.
7 Pressure should be maintained
(30,32) 2 If air bubbles are seen in the
on the thumb button until
syringe, patients should tap
the needle is withdrawn from
3 Needles should be safely the barrel to bring them to the
the skin in order to prevent
disposed of immediately after surface and then remove the
aspiration of patient tissue into
use and not left attached to the bubbles by pushing up the
the cartridge. (158,159)
pen. This prevents the entry plunger.
of air (or other contaminants)
into the cartridge as well as the
leakage of medication, either of
which can affect dose accuracy.
(30,33,147,148,149,150)
21
3.0
Injecting 4.0
Process Injectable therapies
3 Unlike pens, it is not necessary 4.1 Human Insulins 4.2 Insulin Analogues and
to hold the syringe needle GLP-1 agents
under the skin for a count of
10 after the plunger has been 1 Intramuscular (IM) injections 1 Rapid-acting insulin analogues
depressed.(33,147,157) of Neutral pH suspension may be given at any of the
of crystalline insulin, injection sites, as absorption
4 Syringes must be protamine and zinc (NPH) rates do not appear to be site-
used only once. Fig 11 and long acting insulin must specific. (171,172,173,174,175)
(62,63,68,106,151,152,153,154) be strictly avoided due to
the risk of hypoglycaemia.
(160,161,162,163)
2 Rapid-acting analogues should
be given subcutaneous and not
2 The abdomen is the preferred
IM. (172,173,176)
site for soluble human
insulin since absorption of
3 Patients may inject long-acting
this insulin is fastest there.
insulin analogues in any of
(164,165,166,55,167,95)
the usual injecting sites as
absorption rates do not appear
3 Soluble human insulin /NPH mix
to be site specific. (107)
should be given in the abdomen
to increase the speed of
4 Patients using non-insulin
absorption of these short-acting
injectable therapies should
insulins, in order to cover post-
follow the recommendations
prandial glycaemic changes (56)
already established for insulin
injections with regards to
needle length, site selection
4 If there is risk of nocturnal
and site rotation. (148,177)
hypoglycaemia, NPH and
soluble human insulin mixes
given in the evening should
be injected into the thigh or
buttock as these sites have
slower absorption of NPH.
Figure 11: Syringes must be used only once (168,169,170)

RECOMMENDED
UNRESOLVED ISSUE

5.0
Lipohypertrophy (LH)
Correct Examination 5.1 Setting 5.2 Positioning Patient

For Detection Of 1 Patient should be asked about 1 Patient should be lying down
Lipohypertrophy: abnormalities at injection sites on back (to relax abdominal
The following points are helpful (what, where and how long); muscles) with knees bent
when performing the physical this should guide examinations (to relax thigh [quadriceps]
examination for Lipohypertrophy but not limit it to one area. muscles) and arms folded over
(LH). Having gained consent, the chest (to relax arm muscles).
examination should be performed 2 Patient must then disrobe to
at least once a year on all persons only underclothes. A chaperone 2 If there is no table, an
injecting insulin. For those may be needed in some alternative is for the patient to
found to have LH lesions, the cultures. be sitting, with knees bent and
examinations should be performed arms relaxed in lap.
even more frequently. Fig 12 3 Room must be warm to prevent
patient chilling (this ensures 5.3 Positioning Professional
patient comfort but also
prevents shivering and muscle 1 Hands must be washed and
tension which can interfere with warmed before touching
the examinations). patient.
4 Light should be oblique to the 2 If no adjustable light is

skin (not overhead); the use available, healthcare
of an examining light with an professional (HCP) can wear
adjustable neck is ideal; light head lamp or use flashlight.
should be shined onto skin
surfaces at an angle of 30-45 3 If patient is sitting HCP needs to
degrees. do the examinations seated.
Figure 12: Examples of lipohypertrophy
23
5.0
Lipohypertrophy
5.4 Technique for Visual 5.5 Technique of Palpation 5.6 Measuring and
Examination Documenting the
1 Inspect site with lamp first, 1 After hands are warmed by Lipohypertrophy
adjusting its angle to be able rubbing them together or 1 With the patients consent and
to detect any subtle risings or washing in warm water, apply using skin safe marker pen,
depressions across the surface gel (ultrasound gel or another mark the exact position of the
of the skin. water-soluble lubricant for lesion on the patients skin so
clinical use) to the injecting that the patient can clearly see
2 Lipohypertrophy (LH) is usually area and palpate with the tips of the extent of the lesion and
manifested as a raised or the fingers, working in towards avoid injecting into it.
mound-like, convex pattern with the injecting area with light
no change in skin colour or hair massage-like motions (forward 2 Measure the distance along its
distribution; occasionally it can thrusts or circular sweeps). largest dimension (usually the
be manifested as only a shiny longest diameter) in mm and
or hyper-pigmented (especially 2 Lipohypertrophy is manifest by record in patients chart.
in dark-skinned persons) area a change in the subcutaneous
and/or an area of hair loss. (SC) tissue, which is replaced by 3 Photograph the lesion from
a harder, and more rubbery or a distance of 1 meter without
3 If detected, gain consent and less bouncy tissue. flash, using the light from an
mark centre point with pen so oblique source so as to reveal
that area can be palpated later. 3 Often the edges of this surface contours once consent
abnormal area are clearly has been given.
demarcated and it is easy to
feel the transitional zone, which 4 Use the measurements and
appears as a step-up from the photograph to follow progression
of the lesion long-term.
surrounding soft tissue.
5 Patient should be taught to

do the visual and palpation
examination monthly (using
soap or hand lotion as a
lubricant) and to report any
change to the HCP.

RECOMMENDED
UNRESOLVED ISSUE

5.0
Lipohypertrophy
5.7 Role of Ultrasound in 5.8 Diagnosis and 4 After obtaining patient

Lipohypertrophy Management of consent, making two ink
marks at opposite edges of the
Lipohypertrophy
lipohypertrophy with a single-
1 Ultrasound (US) has been
1 Sites should be examined use skin-safe marker (at the
used in various LH studies
by the HCP at least once junctions between normal and
but its exact role has yet to be
year or more frequently if lipohypertrophic tissue) will
defined, either for diagnosis or
lipohypertrophy is already allow the lesion to be measured
management of the disorder.
present. (142,48) or photographed and its size
recorded for future assessment.
2 US appears to be more sensitive
2 The physical examination for Recording and measuring is
and specific than clinical
lipohypertrophy is ideally important but facilities or time
examination in early clinical
performed with the patient may not always be available.
studies, but this remains to be
lying down with injection areas (5,192,193)
confirmed.
fully exposed and any tight or
restrictive clothing loosened. 5 Patients should be encouraged
3 An US signature for LH may
But in circumstances that by education and guidance
exist and ongoing studies are
preclude this, examination of not to inject into areas of
attempting to define the various
the patient sitting, standing or lipohypertrophy until the next
image profiles of LH.
partially-clothed is acceptable. examination by an HCP. Advise
using larger injection areas
and do not reuse needles.
3 Patients should be taught to (186,194,195,196,197)
inspect their own sites and
should be given training in 6 Switching injections from
site rotation, correct injection lipohypertrophic to normal
technique as well as in tissue often requires a
detection and prevention of decrease in the dose of
lipohypertrophy. (178,179,180, insulin injected. The amount
181,182,183,184,66,67,69,72,73, of change varies from one
44,185,186,84,187,188,189,190, individual to another and
191) should be guided by frequent
blood glucose measurements.
(71,73,186,194,196)
25
6.0
Injection Issues
6.1 Bleeding and Bruising 6.2 Leakage at Cartridge and 6.3 Skin Leakage
Pen Needle (PN) Connection
1 Patients should be reassured 1 Ensure that the pen needle(PN) 1 Use needles with thin-wall or
that local bleeding and is International Organization for extra thin-wall technology.
bruising do not have adverse Standardization (ISO) certified (199,200)
clinical consequences for the compatible with the insulin pen.
absorption of insulin or for 2 Count to 10 after the plunger
overall diabetes management. is fully depressed before
Fig 13 (198) 2 Position the PN along the axis removing the needle from the
of the pen before screwing or skin. This allows enough time
2 If bleeding and/or bruising are snapping it on. for the injected medication to
frequent or excessive, injection spread out through the tissue
technique should be carefully 3 Pierce straight through the planes and/or to cause the
assessed but this may be due to septum of the cartridge. tissue to expand and stretch.
the presence of a coagulopathy (157,199,200)
or the use of an anticoagulant
or antiplatelet agent. 3 A small amount of skin leakage
(little pearl of liquid at injection
site) can be ignored. It is almost
always clinically insignificant.
(157,199,200)
4 For patients who report

frequent skin leakage, a direct
observation of their self-
injection is important to detect
possible technique-related
issues that can be modified.
(157,199,200)
Figure 13: Cluster of injection punctures.

RECOMMENDED
UNRESOLVED ISSUE

6.0 7.0
Injection Issues Pregnancy
6.4 Dripping from the Needle 7.1 Pregnant Women
1 Use needles which have a wider 1 The abdomen is a safe site

inner diameter and improved for insulin administration in
insulin flow (e.g. Extra-thin wall pregnancy. Given the thinning
needles). (201,31) in abdominal fat from uterine
expansion, pregnant women
2 Count to 10 after the plunger with diabetes (of any type)
has been fully depressed before should use a 4 mm pen needle.
removing the needle from
the skin. This is to allow time
for forces to be transmitted 2 First trimester: Women should
through all pen parts to insulin be reassured that no change
column in the pen cartridge. in insulin site or technique is
Fig 14 (199) needed.
3 Larger doses may be split to 3 Second trimester: Lateral parts

reduce the volume of insulin. of the abdomen can be used to
Consider using higher strength inject insulin, staying away from
insulin for large doses to reduce the skin overlying the foetus.
volume. (199,202)
4 Third trimester: Patients may

use the thigh, upper arm or
lateral flanks of the abdomen to
inject themselves.
Figure 14: Count to 10 before removing pen
27
8.0
Technology
8.1 Needle Inner Diameter 8.2 Insulin Infusion Sets 4 All CSII patients should have
(IIS) for Continuous their infusion sites checked
1 High flow rate needles (extra-
frequently or at least annually
thin wall) needles have been Subcutaneous Insulin
for lipohypertrophy by an HCP.
shown to be appropriate for Infusion (CSII)
(205,208)
all injecting patients. Their 1 Population studies suggest
obstruction, bending and that CSII cannulae should be 5 If lipohypertrophy is suspected,
breakage rates are the same as changed every 4872 hours in the patient should be instructed
for conventional quality needles order to minimise infusion site to stop infusing into these
(extremely low), and they offer adverse events and potential lesions and to insert the
distinct flow advantages. Fig 15 metabolic deterioration. cannula into healthy tissue.
(203,204,20,206) (71,145,186,194,195,196,197)
2 All CSII patients should be

taught to rotate infusion sites 6 Silent occlusion of insulin
along the same principles that flow should be suspected in
injecting patients are taught to any patient with unexplained
rotate injection sites. (183,207) glucose variability or
unexplained hyperglycaemia.
(203,208,209,210,211)
3 Any CSII patients with
unexplained glucose 7 If silent occlusion or flow
variability including frequent interuptions are suspected CSII
hypoglycaemia/hyperglycaemia patients should be considered
should have infusion sites for alternative cannulae.
checked for lipohypertrophy, (203,205,209,212)
Vs nodules, scarring, inflammation
or other skin and subcutaneous 8 All CSII patients should be
(SC) conditions that could affect considered for the shortest
insulin flow or absorption. needle/cannula available, along
(207) the same principles as insulin
injectors, to minimise the risk
Figure 15: thin inner diameter needle v thick of intramuscular (IM) infusion.
walled needle. (212)

RECOMMENDED
UNRESOLVED ISSUE

8.0
Technology
9 The smallest diameter needle/ 12 All CSII patients who are lean,
cannula should be considered muscular or active and have a
in CSII patients to reduce pain high probability of the cannula
and the occurrence of insertion or tubing being dislodged may
failure. (212) benefit from an angled infusion
set (30-45 degree). (213)
10 Angled insertion sets should
be considered in CSII patients 13 All CSII patients who have
who experience infusion difficulty inserting their infusion
site complications with set manually for any reason
perpendicular (ninety degree) should insert their infusion
infusion sets. sets with the assistance of a
mechanical insertion device.
11 All CSII patients who experience (213)
a hypersensitivity reaction to
cannula material or adhesive 14 All CSII patients who become
should be considered for pregnant may require
alternative options (alternative adjustments to their infusion
sets, tapes or skin barriers). sets, site locations and
frequency of site changes.
29
9.0
Safety
9.1 Needlestick Injuries/ 3 The use of safety-engineered 6 Health care settings where
Blood-borne Infection Risk devices should be considered insulin pens are used must
for certain autonomous follow a strict one-patient /
1 Safety-engineered devices home-injecting patients with one-pen policy. (230)
play a critical role in protecting diabetes (e.g. those known
injectors, pump users and to be seropositive for Human 7 The optimal safety-engineered
downstream workers, for Immunodeficiency Virus (HIV), device should provide
example refuse workers, Hepatitis B Virus (HBV) and protection for patients, care-
cleaners and porters. Nurses Hepatitis C Virus (HCV), children givers and all others who may
and other HCPs must receive injecting at school, care homes come in contact with the sharp
appropriate education and and prisons). (216,225,226,227) device. (215,216,217,218,219,22
training in how to minimize 0,221,222,223,
risk, by following optimal 224)
techniques, using available 4 Patients with small children
safety devices and wearing at home and/or sub-optimal 8 Manufacturers must investigate
protective clothing (e.g., sharps disposal options all reported needlestick injuries
gloves). (214) should also consider using (NSI) to determine if they are
safety-engineered devices. related to a device failure.
2 Safety-engineered devices (215,217,218,220,221,228)
should be considered first-line
choice if injections are given by
a third party. Pen and syringes 5 HCPs should be involved in
with needles used in these the selection, trial and choice
settings should have protective of devices used in their health
mechanisms for all needles care setting. Evaluation prior
and sharp ends of the delivery to adoption should include key
device. (215,216,217,218,219, specialists (e.g. experienced
220,221,222,223,224) end users, infection prevention
and control and occupational
health). (229,215)

RECOMMENDED
UNRESOLVED ISSUE

9.0
Safety
9 The use of shorter needles (e.g. 12 Needle recapping should not be 14 Review and evaluation of the
4 mm pen needles) without done and manufacturers should effectiveness of education and
a skin fold is recommended design safety-engineered training and of compliance to
to minimize the the risk of devices which make recaping guidelines must be performed
needlestick injury (NSI) through impossible. Fig16 and Fig 17 at regular intervals. A reporting
a skin-fold. (93,102,130,231) (215,217,218,220,221) system for non-compliance
must be put in place. (215,216,2
13 Hospitals must encourage 17,218,219,220,221,222,223,
10 If a lifted skin fold is used, reporting of NSI and near 224)
the patient should ensure misses and establish a no
that finger and thumb are blame culture. Central 15 Attention must be paid to
approximately 2.5cm (1 inch) review of all NSI/near misses the use of safety-engineered
apart and should make the must take place regularly to devices. If they are used
injection in the centre of the allow for policy change and incorrectly or not activated,
fold thus minimizing through- assess educational needs. they provide no additional risk
skinfold NSI risk. (231) (215,217,218,220,221) reduction over conventional
(non-safety) devices (may
11 NSI awareness campaigns lead to dosing errors).
should be carried out (215,216,217,218,219,
regularly and should include 220,221,222,223,224)
all persons in potential
contact with medical sharps.
(217,218,219,220,232,233)
Figure 16: Safety syringe Figure 17: Safety pen needle
31
9.0
Safety
16 Sharps containers must be 18 First aid information what to

easily accessible at the point do in the event of a NSI should
of care beside the patient, be readily available. All workers
prior to the injection or in possible contact with sharps
infusion. Containers should should be aware of local safety
bear the warning, Needles can and disposal regulations.
seriously damage the health Legal, societal and health
of others. Please ensure safe related consequences of non-
disposal or similar. Fig 18 compliance should be reviewed.
(215,217,218,220,221,228) (135)
19 Safe disposal should be taught

17 While Hepatitis B Virus to patients, care-givers and all
(HBV) vaccination should be others who may come in contact
population-wide, the minimum with the sharp device from
standard is its mandatory the beginning of injection or
offering by the employer to all infusion therapy and reinforced
workers exposed to sharps. throughout. (136)
Vaccination status should be
reviewed annually. (234) 20 Potential adverse events of NSIs
should be emphasized to the
patients family, caregivers and
service providers (e.g. refuse
collectors and cleaners).
21 Under no circumstance should

sharps material be disposed of
into the public refuse or rubbish
system.
Figure 18: Sharps container

RECOMMENDED
UNRESOLVED ISSUE

10.0
Golden Rules
10.1 Psychological Issues 10.2 Injection Technique 3 Recommended sites for

around Insulin Therapy and in Adults injection are abdomen, thigh,
buttocks, upper arms:
Administration 1 Insulin and GLP-1 receptor
1 All patients and care givers agonists must be deposited into Abdomen within the following
should be offered general, healthy subcutaneous tissue, areas: 2cm above the
as well as individualised avoiding the intradermal and symphysis pubis, 2cm below
education/counselling which intramuscular spaces as well as the lowest rib, 2cm away from
will facilitate optimal care. scars and lipohypertrophy. the umbilicus and laterally at
the flanks. (Pregnant women
2 Ensure all patients and 2 4mm pen needles are should avoid abdominal sites
carers are supported by their recommended for all adults around the umbilicus during the
HCP using person-centred regardless of age, gender or last trimester)
evidence-based psychological Body Mass Index (BMI). If Upper 3rd anterior lateral
educational tools / strategies to patients need to use needle aspect both thighs
achieve mutually-agreed goals. lengths > 4mm or a syringe Upper, outer quadrants of
(or where the presumed skin buttocks
3 Diabetes HCPs should be skilled surface to muscle distance is Mid 3rd posterior aspect of
in identifying psychological less than the needle length) upper arm, if given by a third
issues which impact on insulin they must use a correctly-lifted party
therapy and administration. skinfold to avoid intramuscular
injections.
4 HCPs must have a range of
therapeutic behavioural skills
to minimise the psychological
distress and impact of insulin
therapy.
5 Various methods of minimizing

barriers, pain and/or fear of
injection should be utilised in
order to reduce psychological
impact.
33
10.0
Golden Rules
4 Inspect site before injecting and 10.3 Injection Technique in 3 Consideration should be given
avoid areas of lipohypertrophy. Children and Young People to the type of insulin and the
time of day when selecting
5 Rotation of injection sites within 1 Insulin must be injected injection sites.
an area is recommended: into healthy subcutanous
Spacing injections (SC) tissue, avoiding 4 Correct rotation of injection
approximately 1 cm breadth the intradermal(ID) and sites must be followed
apart intramuscular (IM) tissue at all times to prevent
Using a single injection as well as lipohypertrophy, lipohypertrophy.
site no more frequently lipoatrophy and scar tissue.
than every 4 weeks when 5 4mm pen needles should be
feasible. 2 Injections should avoid bony used for all children and young
Avoid mixing injection areas prominences by one to two people regardless of age,
and insulin type centimetres. Sites, in order of gender or BMI.
preference are:
Upper outer quadrant of the 6 Children and young people
upper buttocks are at risk of accidental IM
Abdomen, two centimetres injection particularly in the
away from umbilicus thigh; therefore, always use a
Middle 3rd of the back of the lifted skinfold especially if using
upper arm a pen or syringe with a safety
Upper outer 3rd of both needle attached.
thighs

RECOMMENDED
UNRESOLVED ISSUE

10.0
Golden Rules
10.4 Treating and Preventing Clinicians must document 5 Patients with lipohypertrophy
Lipohypertrophy lipohypertrophy and other who have been instructed to
site complications in patient stop injecting/infusing into
1 All HCPs in diabetes must be records affected tissue must be:
trained in correct injection Patients should
technique and to correctly ducated about the
E
be encouraged to
screen for lipohypertrophy and improved/changed
avoid injecting into
other site complications. absorption when injecting
lipohypertrophy or
into normal tissue instead of
unhealthy sites
2 All patients, caregivers, and lipohypertrophy
Clinicians must monitor
family members must be taught and record any area of Advised that pain may be
the techniques of correct lipohypertrophy to map experienced when injecting
injection or infusion at the change, possibly using the into normal tissue
initiation of therapy and at following tools: ncouraged by a HCP to
E
subsequent reviews, at least on -- Photography monitor glucose levels
an annual basis. -- Body maps with frequently due to the risk of
descriptors for size, unexpected hypoglycaemia
3 Injection sites should be shape, texture
checked by a HCP on a regular -- Transparent graduated
Supported to reduce their
basis, at least annually or more recording sheets. insulin doses in line with
often if LH has been detected. glucose results, knowing
ith patient consent,
W that reductions often exceed
4 All persons who self-inject/ clinicians should mark the 20% of their original dose
infuse insulin or other border of all lipohypertrophy Changed to 4mm pen
injectables must be taught to and other site complications needles/8mm insulin
self-inspect sites and be able with skin-safe single- syringes or the shortest
to distinguish healthy from use markers and instruct needle length available
unhealthy tissue. patients to avoid using to minimise accidental
marked areas until intramuscular risk due to
instructed otherwise using larger areas
35
10.0
Golden Rules
6 All patients must be encouraged 10.5 Insulin Infusion 4 Infusion cannulae sites
to correctly rotate injection/ Technique should be rotated to avoid
infusion sites and educated lipohypertrophy. This involves
of the risks of reusing needles 1 Insulin infusion cannulae full rotation within each site.
in order to minimise risk of must be inserted into healthy
injection site complications: subcutaneous tissue, avoiding 5 Infusion cannulae should be
underlying muscle as well changed within 72 hours.
rinciples of correct rotation
P as areas of skin irritation,
technique must be taught scarring, lipohypertrophy and 6 If kinking occurs consider a
to patients and rotation lipoatrophy. shorter cannula or an angled or
technique assessed at steel infusion set.
least every year and more 2 If bleeding or significant pain
frequently if required occurs upon insertion, the 7 If silent occlusion, interuption
Correct rotation ensures set should be removed and in flow or unexplained
that injections are spaced replaced. hyperglycaemia occur, consider
out approximately 1 cm (a using a cannula with a side port.
finger breadth) from each 3 Preferred sites for infusion
other and that a single cannulae should be
injection site is used no individualised and include:
more frequently than every 4
weeks when feasible. Abdomen, avoiding bony
prominences and umbilicus
Upper outer quadrant of the
upper buttocks and flanks
Middle 3rd of the back of the
upper arm
Upper outer 3rd of both
thighs

RECOMMENDED
UNRESOLVED ISSUE

10.0
Golden Rules
10.6 Needlestick Injuries and 3 Safety-engineered devices must 7 Insulin delivery by 3rd party
Sharps Disposal be used by all HCPs and by all carers or family member must
3rd party carers using sharps be carried out using correct
1 All HCP, employers and (e.g. injections, blood testing, injection or infusion techniques
employees must comply with infusion) in situations where a and with safety-engineered
relevant international, national risk for disease transmission devices which shield/guard the
and local legislation for the use (i.e. Human Immunodeficiency patient end of the needle at a
of sharps. Virus [HIV] and hepatitis) minimum. Best practice for pen
may be present, and in risky needles requires that both ends
2 Sharp medical devices environments such as care of the needle be protected.
present a potential risk for homes, schools, and prisons.
injury and transmission of
disease. All HCPs, employers 4 Frequent and regular sharps
and employees must ensure awareness campaigns must be
the safest possible working conducted by all employers for
environment by: personnel at risk of contact with
medical sharps.
Conducting regular risk
assessment in all situations 5 Recapping of needles is strictly
where there is potential for prohibited (except by the self-
exposure to sharps injury injector).
Preventing and controlling
risk by means of continuing 6 Where possible safety-
education and training engineered devices with
Providing and using a means passive activation should be
of safe disposal of used used.
sharps conforming with
National standards
Encouraging reporting of
incidents
37
10.0
Golden Rules
8 Safe disposal requires that:
Correct disposal
procedures and personal
responsibility be taught to
patients and care givers
by the dispensing clinician
(including pharmacists) and
be regularly reinforced
Safe sharps disposal
systems and processes be
present and known to all
persons at risk of sharps
contact (conforming to
National standards)
Environments where others
are at risk of exposure to
sharps (e.g. care homes,
schools and prisons or
around refuse workers and
cleaners) be highlighted to
the patient
Patients diagnosed with
blood bourne diseases such
as Human Immunodeficiency
Virus (HIV) or Hepatitis be
supported to use safety-
engineered devices and
dispose of them safely
Sharps should never be
placed directly in public or
household rubbish

FIT UK
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45
The UK Injection and

Infusion Technique
Recommendations
4th Edition Contributors 2016
FIT Board Reviewers Jenny Berlanga

Debbie Hicks Chair Adele West Jo Reed
Dr Debra Adams Amanda Epps Jo Willey
Carole Gelder Andrea Biddulph Julia Bundock
Jane Diggle Angela Pearsall Julia-Anne Coates
Angela Thomas Katie Bowling
Anne Beckett Lesley Kelleher
Getting FITTER attendees Belinda Allen Linda Chapman
Amanda Epps Bev Cunningham Linda Clapham
Carrie Felgate Beverly Chipchase Linda ODonahugh
Catherine Finlay Carole Clive Liz Gilbert
Claire Vick Carolyn Hogg Louise Gebhard
Elaine Belshaw Catherine Finlay Lynne Jennings
Helen Carter Charlotte Simpson Lynne Thomas
Jan Prout Claire Vick Michelle Kain
Jennifer Pichierri Dawn Anderson Neka Agbasi
Jenny Berlanga Denise Pool, Nicky Mead
Julia Bundock Elizabeth Moore Nicola Jackson
Kamel Rohama Emma Guy Nicola Milne
Linda Clapham Fiona Campbell Nina Patel
Liz Moore Gareth Thomas Pam Sherriff
Louise Gebhard Gillian Harding Sam Rosindale
Nina Patel Helen Butterworth Sarah Almond
Sam Rosindale Helen Carter Sarah-Jane Daley
Sophie Fear Helen Horsley Sarah Orme
Suzanne Wiler Hilary Whitty Sophie Fear
Tracy Adams Jackie Webb Sue Jones
Jacqueline Leon Susan Stockley
Jadwiga Borns Suzanne Wiles
Jane Higginson Tara Kadis
Jane Morgan Tracy Adams
Janet Prout Trish Powell
Jayne Cameron
Jenni Wallace

Abbreviations
BMI Body Mass Index (kg/m)

CBT Cognitive Behavioural Therapy
cm centimetre
CSII Continuous Subcutaneous Insulin Infusion
GLP-1 receptor agonist Glucagon-like peptide-1 receptor agonist
HbA1c N-(1-deoxy)-fructosyl-haemoglobin , glycated haemoglobin
HBV Hepatitis B Virus
HCB Hepatitis C Virus
HCP(s) Healthcare Professional(s)
HIV Human Immunodeficiency Virus
IIS Insulin Infusion Set
IM Intramuscular
ISO Certified International Organization for Standardisation Certified
IT Injection Technique
LH Lipohypertrophy, Lipo
m metre
mm millimetre
NPH Neutral pH suspension of crystalline insulin, protamine and zinc
NSI Needlestick Injury
PN Pen Needle
S C Subcutaneous
T1DM Type 1 Diabetes Mellitus
T2DM Type 2 Diabetes Mellitus
US ultrasound
47
Optimising
Diabetes Care
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FIT UK Recommendations For Injection Technique

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FIT UK Recommendations For Injection Technique

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DIABETES CARE IN THE UK

The Forum for Injection Technique (FIT) UK provides

To identify, and provide information on Best Practice and

To raise awareness of the impact that existing and emerging

To facilitate opportunities, in which best practice can be

Over 16 years ago a small pioneering group of

FIT UK was established following the 3rd International Injection Technique

Diabetes UK estimates that more than one in sixteen people in the UK

Diabetes diagnosis rates are equivalent to:

4 DATE PUBLISHED: October 2016

New and emerging evidence shows that optimal injection technique is

A study by Grassi (6) demonstrated that a multimodal approach to

FIT UKs overarching mission is:

To support people with diabetes using injectable

FIT UK is committed to supporting the implementation of the

6 DATE PUBLISHED: October 2016

Preface and Objectives 3

1.0 Psychological Challenges of Injections 11

Diabetes UK both welcomes and supports the FIT initiative.

8 DATE PUBLISHED: October 2016

BD Medical Diabetes Care

For the scientific support the following scale was used.

10 DATE PUBLISHED: October 2016

At least one rigorously performed study,

1.1 Emotional and

5 In the case of fear provoked by

12 DATE PUBLISHED: October 2016

At least one rigorously performed study,

12 If the same injection site is used

13 If pain is experienced when

14 DATE PUBLISHED: October 2016

At least one rigorously performed study,

3.1 Injection Site Care 5 Patients should not inject

1 The site should be inspected by

2 Soiled skin should be cleaned

3 Disinfection of the site is

4 Patients should never

Figure 3: Check the injection site. Ensure both

16 DATE PUBLISHED: October 2016

At least one rigorously performed study,

3.2 Re-suspension of Cloudy 5 Store unopened insulin in a

the subcutaneous tissue, with

little risk of intramuscular

adults (BMI 19-25), injections

(or intradermal) injection.

Longer pen needles increase

Figure 6: Intramuscular injection (IM)

18 DATE PUBLISHED: October 2016

At least one rigorously performed study,

10 Health care authorities and

20 DATE PUBLISHED: October 2016

At least one rigorously performed study,

22 DATE PUBLISHED: October 2016

At least one rigorously performed study,

Correct Examination 5.1 Setting 5.2 Positioning Patient

4 Light should be oblique to the 2 If no adjustable light is

Figure 12: Examples of lipohypertrophy

5 Patient should be taught to

24 DATE PUBLISHED: October 2016

At least one rigorously performed study,

5.7 Role of Ultrasound in 5.8 Diagnosis and 4 After obtaining patient

4 For patients who report

Figure 13: Cluster of injection punctures.