•Voice Over , Transcript and References:

1
Welcome to the Diabetes e-Learning suite. Module 6 discusses the
current guideline recommendations on the diagnosis of diabetes and
the role of specialists in the lifestyle management.

2
After completing this module, you should be able to describe the physiological
function of insulin and the pattern of normal insulin secretion, discuss the
pathophysiology of Type 1 diabetes mellitus, Type 2 diabetes mellitus and
fluctuations in insulin release in T2DM, review the indications for insulin
treatment, identify the barriers to commencing insulin, evaluate the initiation
and intensification in insulin therapy and list the side effects of insulin.

3
Let us first review the screening and diagnostic criteria for prediabetes and diabetes in
this section.

4
Insulin therapy is vital in managing the blood glucose levels in people
with type 1 and in some people with type 2 diabetes. For the
treatment with insulin to be effective, it is necessary that the person
with diabetes and the caregiver masters the insulin administration
technique. It is important to become familiar with the chosen method
of delivery such as syringes, reusable or prefilled disposable insulin
pen and insulin pumps. The syringes are standardised to the
concentration of insulin, which allows the preparation of intermediate-
and rapid-acting insulin in the same syringe as per the desired
proportions. Prefilled syringes are advantageous to people who are
dependent on others for care, are travelling or those with an
unpredictable lifestyle. Insulin pens contain a cartridge of insulin that
is inserted into the pen or is prefilled with insulin and can be discarded
after use. Insulin pens allow accurate doses and are preferred for
people with disabilities, neurological deficits and/or requiring multiple
daily doses. Insulin pumps are small devices, which allow the
administration of insulin subcutaneously with a pre-programmed
continuous output and reinforcements triggered by the person with
diabetes during meals.[1]

5
Insulin can be injected into the subcutaneous tissue of the outer arm
or at the back of the arm, the anterolateral region of the thigh, the
abdominal region (except 2.5 cm area in the peri-umbilical region),
the back, buttocks and waist. The site of injection significantly
influences the absorption rate. The abdominal region provides quick
absorption, so it is important to choose this location for injections
during the daytime. In the thigh, intermediate- and long-acting
insulins can be administered and the buttocks region can be used as
an alternative site. Exercise may increase the absorption rate of
insulin by increasing the blood flow in the subcutaneous tissue of the
specific region. However, injecting at the same site every time may
lead to the formation of hard lumps or extra fatty deposits known as
lipodystrophy. Lipodystrophy causes absorption irregularities, thus
mandating regular rotation of the injection site. Rotation can be
carried out within the same area maintaining a distance of about 3 cm
between each administration. Most forms of rapid- and long-acting
insulin absorb consistently from any of the injection sites; however,
intermediate-acting insulin need to be injected at the same injection
site consistently. [1,2]

6
A person with diabetes should be encouraged to self-administer, where
the role of the diabetes educator is cardinal. The slide provides a
stepwise guide for dose preparation and administration. Before each
injection, the insulin label should be verified for the correct insulin and
expiry date. The hands and the injection site should be cleaned
properly. The insulin in the vial should be rolled between the palms,
except for rapid- and short-acting insulin and insulin glargine. Next, an
amount of air equal to the amount of insulin should be withdrawn and
injected into the vial to avoid vacuum. This is important to allow air in
both the bottles before drawing the dose. While mixing rapid- or short-
acting insulin with intermediate- or long-acting insulin, the clear rapid-
or short-acting insulin should be drawn into the syringe first. Once the
needle is within the vial, the insulin vial and syringe should be turned
upside down. After the insulin is drawn into the syringe, the fluid
should be inspected for air bubbles and injected slowly into the
defined site.[1]

7
Insulin pens revolutionised the life of people with diabetes, who earlier
had to use large and painful needles that had to be sterilised before
use. The advantages of insulin pens include the following: more
convenient and easier to use; more accurate dosing; no need of
sterilising the material; less pain due to smaller-gauge needles being
used; more discreet and less scary than a syringe; has improved
social acceptability; more flexibility because of disposable or reusable
options; can be used with all insulin types; doses can be easily dialled;
less wastage of unused insulin (300 units in each pen/cartridge);
improved quality of life; and easier compliance with insulin regimen.
The disadvantages of insulin pens include the following: modest hand
strength needed to push the button on the pen; it cannot mix different
kinds of insulin together in a prescribed dose; is slightly more
expensive than insulin vials; and has limited cartridge size.[1]

8
A person with diabetes should be encouraged to self-administer, where
the role of the diabetes educator is cardinal. The slide provides a
stepwise guide for dose preparation and administration. The following
steps are to be followed for insulin injection preparation and injection
procedure. The insulin label should be verified for the correct insulin
and expiry date. The hands and the injection site should be cleaned
properly. Insulin should be checked for any changes in the
appearance. Do not use the insulin if it appears to have changes, that
is clumping, frosting, precipitation, or change in clarity or colour. It
may signify a loss in potency. If uncertain about the potency of a vial
of insulin, you should replace the vial in question with another of the
same type. Rapid-acting, short-acting and long-acting insulins should
appear clear. Intermediate and pre-mixed insulin should appear
uniformly cloudy. This type of insulin should be gently mixed before
use. To do this, the insulin in the vial should be rolled between the
palms and the pen should be turned up and down 10 times. While
using a reusable pen the cartridge is inserted, the pen is opened and
used, the cartridge is removed, the embolus is pressed until the end
and a new cartridge is inserted with the spinning end or rubber seal
first and the pen is closed.[1]

9
The techniques of dose preparation and insulin delivery is similar for
both prefilled and reusable pen. The protective tab form the needle is
removed and screwed onto the pen until snug. Both the plastic outer
cap and inner needle cap is removed. Once a disposable needle is
screwed on to the pen and the pen is primed, it is dialled to the
appropriate dose, which can be seen in the device’s display window
and can be heard as audible clicks in the pen. Individuals should be
aware that air bubbles in a pen can reduce the rate of insulin flow
from the pen. Therefore, to avoid this, priming the needle with 2 units
of insulin before injection should be done. Then the pen with the
needle should be pointed upwards and the button should be pressed
until at least a drop of insulin appears. This is the ‘air shot’ or safety
shot. While injecting, at least 1 inch (2.5 cm) from the last injection
site, from any scars or from the belly button should be avoided. The
needle is inserted subcutaneously and the plunger injection button is
depressed to deliver the dose. The pen needle should remain in the
subcutaneous tissue for 5 seconds after complete depression of the
plunger to ensure complete delivery of the insulin dose. The pen
should be held in such a way that the thumb should be on the dosing
knob. Next, the pen is injected at an angle of 45° or 90° and pressed
for 6 to 10 sec. Then the inner needle cap over the needle is carefully
replaced and removed and the cap is restored.[1]

10
Injection technique is critical for therapeutic success of insulin therapy.
Improper use or reuse of devices may lead to bruising, swelling,
redness, pain, dosage inaccuracy, lipodystrophy and poor glycaemic
control. Painful injections can be minimised with little care, such as
injecting the insulin at room temperature, removing air bubbles,
making sure that alcohol (if used) is evaporated completely before
injection. Keeping the muscles relaxed during administration, rapid
and quick insertion of the needle, not changing the direction of the
needle during insertion or withdrawal and preventing reuse of the
needles.[1,2]

11
The continuous subcutaneous insulin infusion (CSII) systems (the so
called insulin pumps) are small computerised devices that can be
attached to a waistband, pocket, undergarment, belt and pants. These
are programmed to deliver the ‘basal’ insulin in a steady measured
and continuous dose over 24 hours, the ‘bolus’ insulin dose around
mealtime to control the increase in the blood glucose level after a
meal and correction or supplement doses. They provide better
glycaemic control and are preferred over injections by many
individuals. They are indicated in conditions such as inadequate
glycaemic control (A1c >7%); increase in the blood glucose level early
morning, known as the dawn phenomenon; marked variability in
glucose daily; extreme insulin sensitivity; hypoglycaemic episodes
requiring assistance or hypoglycaemia unawareness; the need for
flexibility in lifestyle to avoid multiple injections and pregnancy or
intention to become pregnant; and chronic complications that would
highly benefit from improved glycaemic control such as gastroparesis,
early neuropathy or nephropathy and renal transplantation.[1,2]

12
Insulin pump is more advantageous as it provides more physiologic
insulin delivery, eliminates the need for individual and multiple insulin
injections, delivers insulin more accurately than injections, often
improve A1C levels, results in fewer blood glucose level fluctuations,
makes delivery of bolus insulin easier, provides flexibility in eating
pattern, reduces severe hypoglycaemic episodes, provides improved
quality of life, reduces unpredictable effects of intermediate- or long-
acting insulin and allows to exercise without having to eat large
amounts of carbohydrates. The disadvantages of using an insulin
pump include weight gain, risk of diabetic ketoacidosis, higher costs
than other injectable and a need to get trained. [1,2]

13
This slide demonstrates the advantages of using insulin pump over an
insulin pen.[1]

14
In order to start the insulin pump therapy, the healthcare provider
needs to determine the amount of insulin to use in the insulin pump
by averaging the total units of insulin per day for several days. The
total dosage is then divided into 40% to 50% for basal and 50% to
60% for bolus insulin and the hourly basal rate is determined by
dividing the basal portion by 24. Later, the hourly basal rate is
adjusted according to the dawn phenomenon and daily activity. This is
followed by evaluating the insulin-to-carbohydrate ratio. The dose of
insulin to correct high blood glucose is determined by the healthcare
team.[1]

15
The individual with diabetes and/or the caregiver should be educated
on the storage of insulin, which directly impacts its potency and hence
the blood glucose control. Specific storage guidelines provided by the
manufacturer should be followed. Vials of insulin not in use should be
refrigerated, away from the freezer place ideally between a
temperature of 2°C and 8°C. Extreme temperatures (<36 or >86°F,
<2°C or >30°C) and excess agitation should be avoided to prevent
the loss of potency. The vial should be checked for clumping, frosting,
or precipitation before each use. Out of the refrigerator, it can be used
for 30 days between 15°C and 30°C. While travelling, insulin should
be protected from light and extreme temperatures and should be
returned to the refrigerator post travel. Unopened insulin pens can be
stored at about 40°F (4.4°C). Opened pens can be stored at room
temperature, but not above 86°F (30°C). A loss in potency may occur
after the bottle has been in use for more than a month, especially
when stored at room temperature. The person with diabetes and or
the caregiver should be educated to try to relate any unexplained
increase in the blood glucose to possible reductions in insulin
potency.[1,2]

16
Starting insulin therapy is the beginning of a long process of learning
throughout life, where the increased responsibility relates to all
aspects of self-care. This process is related to the emotions of the
person with diabetes and hence given the opportunity to express
whenever possible and necessary. This can help to set up a trusting
relationship with the health professionals team. The first step can be
empowering the person with the care to be taken during insulin
administration. Proper dosing, cleaning up the injection site and
hands, injecting the correct way, routinely checking the injection sites
and proper storage of insulin are primal to insulin administration. The
slide provides a comprehensive checklist of the important
communication pointers the healthcare provider needs to be aware of,
in order to deliver desirable care.[1,2]

17
Children and adolescents experience more discomfort with injections
than adults and face challenges related to frequency, dosing and
timing of insulin. It is important to provide them the emotional and
educational support. In addition, the involvement of parents,
caregivers and school personnel in insulin administration can be
helpful to overcome the barriers. Pregnant women require close
monitoring of the blood glucose levels and dose adjustment of insulin
particularly during the first trimester, where hypoglycaemia is more
common. Injecting around the umbilicus during the last trimester
should be avoided. In elderly people, careful assessment of the
person’s capacity for self-injection is required. Other important aspects
to consider include education on dial visibility, ease of recapping the
pen, rotation techniques and identifying the sites of more effective
absorption.[1]

18
Let us now summarise the key points of this module. Diabetes
educator plays an important role in educating the individual to ensure
successful insulin administration. Injection technique is critical for
therapeutic success of insulin. Improper use or reuse of devices may
lead to bruising, swelling, redness, pain, dosage inaccuracy,
lipodystrophy, poor glycaemic control. Insulin can be injected into the
subcutaneous tissue of the outer and back of the arm, of the
anterolateral of the thigh, the abdominal region, with abdomen being
fastest absorption site. Injection in the same place each time may lead
to the formation of hard lumps or extra fatty deposits known as
lipodystrophy and therefore, injection site should be rotated. Vials of
insulin not in use should be stored at proper temperature to prevent
loss of potency.

19