For insulin therapy to be safe and effective, patient adherence to specific preparation and injection routines is required. Patient education should include appropriate storage, injection technique, accurate dosages, and site rotation.

Storage:

• Store insulin according to the manufacturer`s instructions.
  • Insulin vials not being used should be refrigerated (usually between 36 and 86 degrees Fahrenheit).
  • Extreme temperatures destroy insulin.
  • Excess agitation should be avoided to prevent loss of potency, clumping, frosting, or precipitation.
• Examine vials of insulin for sediment or other visible changes.
  • Regular insulin, lispro, aspart, and glargine are clear insulins.
  • All other types of insulin are suspensions and milky in color.
  • A clear insulin preparation that is cloudy or discolored or an insulin suspension that shows clumping or has a frosty appearance indicates that the insulin may be contaminated or has lost potency and should be discarded or returned to the pharmacy.
• Patient prepared prefilled syringes should be refrigerated and used within 30 days.
• Insulin should be protected from direct sunlight.

Preparation:

• Newly diagnosed patients will benefit from patient education and learning tools.
• Stress the importance of:
  • injection site selection
  • skin preparation
  • medication handling
  • verification of expirations dates
• When mixing two types of insulin in a single syringe
  • rapid-acting or regular insulin is drawn up first, followed by the longer acting insulin.
  • insulins to be mixed should be of the same commercial brand.
• commercially prepared insulin mixtures are accurate, stabilized and convenient which may improve safety, compliance and benefit the patient.

Administration

Insulin is rapidly broken down in the gastrointestinal tract, it cannot be taken orally. The only FDA approved inhaled insulin product has been withdrawn by the manufacturer. Therefore, insulin must be delivered parenterally.

Insulin should be injected into the deep subcutaneous fat. It is recommended that the same anatomical area be used for injections given at the same time of day. The exact site should be changed systematically to utilize the entire area. In type-1 adults, the abdominal wall is the preferred site for mealtime injections. An extended profile of action can be obtained when type-1 adults inject long acting suspensions like NPH in the thigh rather than the arm or abdominal wall.

There are a variety of insulin delivery devices available today. The typical device is a disposable U-100 syringe and needle. Syringe sizes range from .25cc to 1cc. Needle length can be 5/16 or 1/2 inch. Selection of needle length should be based upon injection site. Needle angle should enter the skin at 90^o for adults and 45^o for thin adults and children.

Optimal compliance with the ordered insulin regimen may require more than one type of delivery device. Alternatives to the needle and syringe include:

• automatic syringe & needle injectors
• pen injectors
• needle-free jet injectors
• insulin pumps

Device appropriate disposal containers are part of a complete insulin regimen.

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The American Diabetes Association (ADA) has a wealth of resources. Check out this address and click on links for basic diabetes, type 1 and type 2 diabetes info.

This ADA link is for health professionals, and offers Practice Recommendations and numerous Position Statements from the ADA's Diabetes Care Journal.

Check on this position statement for insulin administration, and look for the answer to the following questions.

When should insulin vials be refrigerated and why?

When should insulin vials be kept at room temperature and why?

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