Supporting Self-management of Diabetes With Education in the Pharmacy

This article was sponsored by embecta (formerly part of BD).

THIS BRIEF TOOL PROVIDES INFORMATION to help pharmacists prepare for counseling sessions with patients with diabetes who use injectable therapy. The information below emphasizes the importance of diabetes self-management including recommendations by the American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2023.¹

KEY COUNSELING POINTS

Glycemic control may involve different needs for each patient. Remind patients that their injection experience and glucose levels may be affected by injection variables that they can control, such as:

• using a new needle for each injection²;
• injecting with shorter (4 mm pen needles and 6 mm syringes) needles¹; and
• rotating injection sites.¹

RISKS OF BLOOD GLUCOSE VARIABILITY AND COMPLICATIONS ASSOCIATED WITH IMPROPER INJECTION TECHNIQUE

1. Correct injection site rotation appears to be the critical factor in preventing lipohyerptrophy.³
2. Lipohypertrophy is an accumulation of fat that presents as soft, elevated areas of the skin disrupting the absorption of insulin and causes glycemic variability (changes in blood glucose levels).¹ In a study, unexplained glycemic variability was 7 times higher in patients with lipohypertrophy.^3,a
3. Unexplained hypoglycemia (low blood glucose; < 70 mg/dL).¹ In one study, the rate of repeated unexplained hypoglycemia was more than 6 times higher in patients with lipohypertrophy.^3,b

INJECTION TECHNIQUE TRAINING

Nearly 50% of patients with diabetes reuse their needles.² Reusing needles may cause them to dull, making injections more painful.¹ Practicing proper injection technique, including using a new needle for every injection, helps to reduce the risk of potential complications associated with reuse. In one study, patients with diabetes who were prescribed insulin and who received structured injection technique training by a clinician experienced a 1% reduction in hemoglobin A_1c (HbA_1c) level at 6 months.^4,c

^a430 patients with diabetes who had been injecting insulin for at least 1 year were observed on their injection technique (ie, site rotation, area of injection, frequency of needle/syringe reuse) as well as the presence of LH. 49% of patients with LH reported having episodes of glycemic variability vs 7% without LH [P < .01]. “Glycemic variability” was defined as oscillations of blood glucose values from < 60 mg/dL to > 250 mg/dL at least 3 times a week in an unpredictable and unexplained fashion.³

^b430 patients with diabetes who had been injecting insulin for at least 1 year were observed on their injection technique (ie, site rotation, area of injection, frequency of needle/syringe reuse) as well as the presence of lipohypertrophy (LH). 39% of patients with LH reported having episodes of unexplained hypoglycemia vs 6% without LH [P < .01]. “Frequent unexplained hypoglycemia” was defined as having a hypoglycemic episode (blood glucose reading of ≤ 61 mg/dL) one or more times a week in the absence of a definable precipitating event, such as a change in medication, diet, or activity.³

^cBased on an RCT pilot study, 116 patients with diabetes (mostly T2DM) on insulin were randomized into 3 groups to assess the change in A_1C over 6 months. Groups 1 and 2 received structed injection training and group 3 was the control. Baseline A_1C for all groups were similar (mean: 85-88% [± 1.4 – 1.9%]). At 6 months, mean [95% CI] reductions in A_1C from baseline were significant in groups 1 and 2 (- 1.00% [- 1.3 to - 0.6%] and - 1.00% [- 1.4 to - 0.7%], respectively; P < .001 for both). The mean A_1C reduction in the group 3 was not significant (- 0.02% [- 1.2 to 1.6%]).⁴

^dAlways check your pen manufacturer’s instructions for use.⁵

PEN NEEDLE SELECTION CONSIDERATIONS
Use of shorter needles (4-5 mm) can help patients to avoid intramuscular insulin injection regardless of their age, sex, body mass index, or obesity status.^1,5 Remember to ask patients if they need more needles when refilling a prescription for insulin.

^a226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of > 0 mm; clinically significant difference of ≥ 5 mm). BD Nano™ 2nd Gen demonstrated superiority vs. all comparator groups combined for overall preference. [(P < .05) (Mean +17.5 mm, 95% CI, +10.3 to +24.7 mm)].⁶

^b226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of >0 mm; clinically significant difference of ≥5 mm). BD Nano™ 2nd Gen demonstrated superiority vs. all comparator groups combined for overall ease of use. [(P < .05)(Mean 19.9 mm, 95% CI, +13.8 to +25.9 mm)].⁶

^c226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of > 0mm; clinically significant difference of ≥ 5 mm). BD Nano™ 2nd Gen demonstrated superiority vs all comparator groups combined for feeling more comfortable throughout injection experience. [(P < .05) (mean + 18.0 mm, 95% CI, +11.6 to +24.3 mm)]. *226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of > 0 mm; clinically significant difference of ≥ 5 mm). BD Nano™ 2nd Gen demonstrated superiority vs. all comparator groups combined for ease of attachment. [(P < .05) (Mean +21.8 mm, 95% CI, +16.1 to +27.6 mm)].⁶

^d226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of > 0 mm; clinically significant difference of ≥ 5 mm). BD Nano™ 2nd Gen demonstrated superiority vs all comparator groups combined for ease of grip and removal of the inner shield. [grip (P < .05)(mean +23.8 mm, 95% CI, +18.1 to +29.4mm)]; [removal (P < .05) (mean +24.4 mm, 95% CI, +18.9 to +29.9 mm)].⁶

^e226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of > 0 mm; clinically significant difference of ≥ 5 mm).⁶

^fCompared to longer needles.⁶

^g226 patients with diabetes on insulin treatment were studied with a 150 mm visual analog scale (mean scores of > 0 mm; clinically significant difference of ≥ 5 mm). BD Nano™ 2nd Gen demonstrated superiority vs all comparator groups combined for feeling more comfortable throughout injection experience [(P < .05) (mean +18.0 mm, 95% CI, +11.6 to +24.3 mm)].⁷

^h1188 injections administered in swine across a range of injection forces using 20 μl of iodinated contrast delivered with BD Nano™ 2nd Gen vs three 4 mm posted-hub pen needles. Measurements were obtained via fluoroscopic imaging. BD Nano™ 2nd Gen more closely achieved the 4mm target injection depth with less variability (P = .006).⁷

References

1. American Diabetes Association Professional Practice Committee. Standards of Medical Care in Diabetes—2023. Diabetes Care. 2023;46(suppl 1):S1-S291. https://diabetesjournals.org/care/issue/46/Supplement_1
2. Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide injection technique questionnaire study: population parameters and injection practices. Mayo Clin Proc. 2016;91(9):1212-1223. doi:10.1016/j. mayocp.2016.06.011
3. Blanco M, Hernández MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013;39(5):445-453.
4. Misnikova IV, Gubkina VA, Lakeeva TS, Dreval AV. A randomized controlled trial to assess the impact of proper insulin injection technique training on glycemic control. Diabetes Ther. 2017;8(6):1309-1318. doi:10.1007/s13300-
   017- 0315-y
5. Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91(9):1231-1255. doi:10.1016/j.mayocp.2016.06.010
6. Whooley S, Briskin T, Gibney MA, Blank LR, Berube J, Pflug BK. Evaluating the user performance and experience with a re-engineered 4 mm × 32G pen needle: a randomized trial with similar length/gauge needles. Diabetes Ther. 2019;10(2):697-712. doi:10.1007/s13300-019-0585
7. Rini CR, Roberts BC, Morel D, Klug R, Selvage B, Pettis RJ. Evaluating the impact of human factors and pen needle design on insulin pen injection. J Diabetes Sci Technol. 2019;13(3):533-545. doi:10.1177/1932296819836987

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