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Insulin injections with PEN in ten steps
- Wash your hands with soap and water before injecting.
- Put a new needle onto your pen and remove the cap of the pen needle.
- Hold the pen upright and perform an ‘air shot’ by dialling up 2 units and pressing the plunger to expel any bubbles out of the needle.
- Dial up your dose. Use calculator to understand your dose or check with your diabetes educator/doctor.
- Pick a soft fatty area on your thighs, abdomen, buttock or upper arms.
- If you prefer you can raise a fold of fatty flesh between your thumb and fingers.
- Put the needle in and keep the pen straight.
- Push the plunger relatively slowly to inject the dose.
- After the dose has been injected, hold the needle in for 10 seconds to help insulin get delivered.
- Ensure that the used needle bin is deposited into a sharps bin.
Insulin injections with syringes (english)
- The ultimate goal of insulin therapy is to mimic normal insulin levels and achieve adequate glycemic control. Unfortunately, current insulin replacement therapy can only approximate normal insulin levels. Insulin therapy for type 2 diabetes ranges from one injection a day to multiple injections and using an insulin pump.
- Insulin is continuously released from the pancreas into the blood stream. Although the insulin is quickly destroyed (5-6 minutes) the effect on cells may last 1-1/2 hours. When your body needs more insulin, the blood levels quickly raise, and, the converse – when you need less, the blood levels rapidly fall —the situation is different when you have diabetesTypes of Insulin:
Types of Insulin
- Human Insulin and Insulin Analogs are available for insulin replacement therapy.
- Characteristics of Insulin are categorized by differences in Onset, Peak, Duration, Concentration and Route of delivery
- Types of Insulin: There are three main groups of insulins: Fast-acting, Intermediate-acting and Long-acting insulin.
- Injection and infusion are the two ways to deliver insulin.
- The most common insulin delivery method is with an insulin syringe.
- A popular alternative to the insulin syringe is an insulin pen.
- Continuous Subcutaneous Insulin Infusion Device (also known as insulin pumps) are the most sophisticated form of insulin delivery.
- Infusion of Human regular insulin may be injected directly into the vein in a hospital setting under close medical supervision only to facilitate the management of diabetes during surgery or an intensive care stay.
Calculating insulin dose
- Formulas to calculate general total daily requirements, and basal and bolus insulin replacement.
- Approximately 40-50% of the total daily insulin dose is to replace insulin overnight, when you are fasting and between meals. This is called background or basal insulin replacement. The basal or background insulin dose usually is constant from day to day.
- The other 50-60% of the total daily insulin dose is for carbohydrate coverage (food) and high blood sugar correction. This is called the bolus insulin replacement. Bolus – Carbohydrate coverage
- The bolus dose for food coverage is prescribed as insulin to carbohydrate ratio. The insulin to carbohydrate ratio represents how many grams of carbohydrate are covered by 1 unit of insulin.
- Generally, one unit of rapid-acting insulin will dispose of 10-15 grams of carbohydrate. This range can vary depending on an individual’s sensitivity to insulin which can vary according to the time of meal, from person to person, and is affected by physical activity.
- Bolus – High blood sugar correction (also known as insulin sensitivity factor) The bolus dose for high blood sugar correction is defined as how much one unit of rapid-acting insulin will drop the blood sugar. Generally, to correct a high blood sugar, one unit of insulin is needed to drop the blood glucose by 50 mg/dl.
- Finally, to get the total mealtime insulin dose, add the CHO insulin dose together with the high blood sugar correction insulin dose:
- Alternatively, if you measure your body weight in kilograms:Total Daily Insulin Requirement (in units of insulin)= 0.55 X Total Weight in Kilograms
- Basal/Background and Bolus Insulin Doses
- Basal/background insulin dose:= 40-50% of Total Daily Insulin Dose
- The carbohydrate coverage ratio: 500 ÷ Total Daily Insulin Dose
Intensive insulin therapy by Carb Counting
- In Intensive insulin regimens there is an attempt to mimic the body’s normal pattern of insulin secretion, and deliver replacement insulin using the concepts of basal and bolus insulin coverage.
- This insulin regimen includes a basal or background insulin dose and bolus insulin dose to cover the carbohydrate in the food that will be represented by the insulin to carbohydrate ratio (I:CHO), which is typically 1 unit for every 10gm carbohydrates.
- Correction factor, where a high blood sugar correction bolus insulin dose is given to bring the blood glucose back into the target range. This correction factor refers to how much your blood sugar will drop after 1 unit of insulin rapid acting insulin (usually 1 unit drops glucose by 50gm/dl.)
- Intensive insulin therapy is achieved either by either multiple daily injections of insulin (MDI), or Insulin pump therapy.
- Advantages of Intensive Insulin Regimens
– Though it requires more calculation at each meal, they allow for more flexibility in timing and in the amount of carbohydrate content in meals and snacks.
– An accurate insulin dose will also result in better blood glucose control with fewer high and low blood sugars.
– Changes in activity and stress can be accommodated without sacrificing glucose control.
- Difficulties with Intensive Insulin Regimens
– Need to monitor the blood glucose, pre-meal, bedtime, when experiencing a hypoglycaemia.
– Need to learn and count carbohydrates
– Know the various insulin formulae like insulin-to-carbohydrate ratio, blood glucose correction and background dose.
– Understand how different insulin formulations act in your body
– Establish blood sugar goals(pre meal, post meal, bedtime)
– Know how to troubleshoot when your blood sugar is not at your goal
Understand glucose emergency responses(such as what to do for low and high blood sugars, and when to check ketones and use glucagon)
Insulin therapy based on blood sugar levels:
- Common regimens:
- Long-acting insulin (glargine/detemir or NPH), once or twice a day with short acting insulin (aspart, glulisine, lispro, Regular) before meals and at bedtime
- Long-acting insulin (glargine/detemir or NPH), given once a day
- Pre-mixed, or short-acting insulin analogs or Regular and NPH, given twice a day
- General principles:
- The amount of carbohydrate to be eaten at each meal may need to be pre-set.
- The basal insulin dose doesn’t change and adjusted as per the fasting glucose
- The bolus insulin is based on the blood sugar level before the meal or at bedtime
- Pre-mixed insulin doses are based on the blood sugar level before the meal
- Disadvantages of this regimen:
- The method does not accommodate changes in insulin needs related to snacks,stress and other activities.
- One may have to eat the similar amount of carbohydrate at each meal, while the foods may change, the time and the carbohydrate content of the meal should not vary widely.
- One should engage in an equivalent level of activity from day to day without varying much the timing, type or duration of activity. In other words, the life style should be rigid.
- This method may seem easier, because there are fewer calculations. However, to be successful, it requires a strict adherence to a consistent schedule of meals and activity, and following your prescribed diet.
Insulin treatment tips:
- Higher doses (basal and bolus) of insulin may be needed:
- If you are unwell or have an infection
- If you reduce your level of activity
- If you gain weight
- If you are on steroids
- If you are under emotional stress
- During adolescence
- During pregnancy
- Lower doses (basal and bolus) of insulin may be needed:
- If you become more active
- If you lose weight
- If you have problems with kidney function
- Skills check list for successful insulin therapy:
- Monitor your blood-glucose (pre-meal, bedtime, when experiencing a low blood glucose)
- Learn to count your carbohydrates.
- Know your insulin formula, for intensive insulin therapy, this means insulin-to-carbohydrate ratio, blood glucose correction and basal dose. For glucose based insulin dose adjustments monitor and adjust pre-meal dose and bedtime doses based on glucose values)
- Understand how different insulin formulations act in your body (eg premix insulins)
- Establish blood sugar goals before and after meals and how to troubleshoot.
- Understand glucose emergency responses
COVID-19, Steroids and Insulins – Guide
COVID-19, Steroids and Insulins
How to avoid Hypoglycaemia?
Your Questions Answered
Why do I need Insulin? Can I not manage with tablets?
Type 2 diabetes is a progressive disease and over time the capacity of pancreas to make insulin deteriorates due to beta cell depletion. Hence some persons with diabetes may need insulin to keep diabetes under control and to prevent or delay complications of diabetes.
I am afraid of taking Insulin injection.
Present day Insulin pens oﬀer comfort and accuracy are painless with thin needles and are convenience since they combine the insulin container and the syringe into a single unit. Administering insulin would be simple in three steps, just dial the dose, insert the needle and push the button. It can be carried in the pocket or purse.
At what age does a person with diabetes requires insulin?
People with type 1 diabetes require insulin from the beginning but people with type 2 diabetes also may eventually require insulin at some stage of life.
Is insulin prescribed by doctor same as that produced naturally in human body?
Human insulin is bio engineered by recombinant DNA technology to replace what their bodies used to make naturally. Currently there are various insulin analogues which are superior to human insulin as they are more physiological in their action, have a more ﬂexible dosing regimen and cause lesser hypoglycaemia compared to human insulins.
What is the diﬀerence in insulin present in a pen or a vial?
If the brand name and strength of insulin is same, there is no diﬀerence in the insulin component in both pens and vials. There are basically two types of pens. Penﬁll is a reusable insulin pen with an insulin cartridge. It is more economical than preﬁlled pens. When the cartridge is empty, it is disposed oﬀ and a new one inserted in the pen. Preﬁlled pen are disposable pen and when the insulin cartridge is empty, the entire unit is to be discarded.
Does insulin cause weight gain?
People who take insulin to manage their glucose levels may experience weight gain; typically they put on a 1-2 kg when they begin taking insulin. But following a meal plan and exercise can helps. Also, the beneﬁt of optimizing blood glucose levels with insulin usually outweighs the risk and long-term complications.
Does insulin cause hypoglycemia?
In people with diabetes who are taking Insulin, hypoglycaemia mostly happens if they take too much insulin or wrong insulin, eat less/skip a meal or exercise without adjusting insulin dose. With necessary precautions like regular monitoring of blood glucose levels and Insulin dose adjustments most of the hypoglycaemias can be avoided.
What is the ideal time to take insulin?
Various insulin regimens need to be taken at diﬀerent times as per their proﬁles (short /intermediate/long acting). Regular human insulin typically needs to be taken 30 minutes before a meal. Rapid-acting insulin analogues can be taken 5 to 10 minutes before a meal.Ultra- fast acting insulin is also available now which can be taken immediately before or even after taking food.
How and where to take insulin?
The best available method for taking insulin is by subcutaneous injections, the layer of fat between the skin and the muscle. Most of the people with diabetes self-administer insulin. You should pinch up a fold of skin if you prefer and insert the needle upright or at an angle between 45° and 90°. When using a 4 to 6-millimetre pen needle to inject, there is no need to pinch the skin when injecting at a 90° angle. One can take insulin in the abdomen, thighs or back of the upper arm.
However, Insulin is absorbed most rapidly from the abdomen and slowly from the thighs. It is best to use the same part of the body for each of your daily injections as insulin is absorbed at diﬀerent speeds from diﬀerent parts of the body. For example you can inject the arm for morning dose, abdomen for afternoon and thigh for your evening injections. Do not inject your morning dose in the abdomen on Monday and in the thigh on Tuesday. While injecting in abdomen area, keep at least 2 inches away from navel area and keep each of the injections at least two inches width from the last injection. Rotate the injection sites to prevent formation of hard lumps (lipohypertrophy).
How to keep insulin safe while traveling?
Many people travel with insulin and it’s better to always carry the diabetes supplies with you in a place easily accessible whether you’re traveling by plane, train or car. It is vital to carry a prescription letter from your doctor both for security checkpoints at airports and also in case insulin is lost or baggage delayed. In general, stick with the exact brand and formulation of insulin that was prescribed by the doctor and carry enough insulin with you. Insulin of diﬀerent strengths like U-100 or U-40 is available in diﬀerent countries and syringes have to match the new insulin to avoid a mistake in the insulin dose. E.g. U-100 insulin should be taken with U-100 syringe.
You can keep insulin in use at room temperature (below 30 degrees) for around a month, but do not keep insulin in direct sun or any hot place. Extreme temperatures can denature your medications and reduce potency of your insulin. You can always use ice packs or a Cool pouch and keep it along with your insulin pen in a small bag while traveling.
Have more questions?
Would you like to attend our Webinars on Insulin / Diabetes Education
Diabetic hypoglycemia occurs when there is low glucose in the blood which is the main source of fuel for the body and brain. Low blood sugar or hypoglycemia is defined as a blood sugar level below 70 milligrams per deciliter (mg/dL).
Common symptoms could be confusion, Dizziness, fast heart beat, increased hunger, sweating, irritability, poor concentration, headache, anxiety and nocturnal hypoglycemia can present with Nightmares and tiredness, irritability or confusion upon waking. However, severe signs and symptoms can be in the form of fits, unable to swallow food or drink, weakness, slurred speech, double vision, drowsiness, confusion, coma and rarely death.
In an emergency due to hypoglycemia causing unconsciousness one should not give oral foods or fluids for risk of choking, need to seek medical supervision for intramuscular glucagon injection or intravenous glucose infusion urgently.
Hypoglycemia is most common among people who take insulin and also sometimes with oral diabetes medications. Common reasons could be taking too much insulin or diabetes medication, not eating enough or skipping/ delaying a meal or sometimes due to exercise or physical activity without eating more or adjusting your medications and alcohol.
High risk group are those on insulin, children with type 1 diabetes, those with liver and kidney disease, diabetics who suffer from hypoglycemia unawareness and after alcohol consumption.
Prevention of hypoglycemia is the best solution. This can be achieve by regular monitoring of blood glucose, eating regular meals, timely medications, adjusting medicines according to food and exercise, keeping emergency medicines or glucose tablets/powder at hand, avoiding alcohol on empty stomach and finally seeking Endocrinologist help in adjusting medications.
For more information of
Hypoglycaemia, please visit Idea Clinics Patient Education
Patients who are planning for surgery whether it’s for major heart surgery, bone, brain etc or for dental or eye surgery, good glucose control is vital in terms of risks and recovery from surgery. Below are the common aspects for conducting a successful surgery in a patient with diabetes.
Patients Managed With Diet Alone:
- Fasting blood glucose should be measured on the morning of surgery
- If surgery is minor, no specific therapy is required.
- If surgery is major or if blood glucose >200 mg/dl, an intravenous infusion of insulin and dextrose should be considered.
Patients Treated With Oral Antidiabetic Agents
- Sulfonylureas should be discontinued 1 day before surgery and metformin has to be withheld couple of days before surgery due to increase risks for renal hypoperfusion, tissue hypoxia, and lactate accumulation. Patients treated with metformin should withhold the drug for ∼72 h following surgery or iodinated radiocontrast procedures. Metformin therapy can be restarted after normal renal function and absence of contrast-induced nephropathy.
- For minor surgery, perioperative hyperglycemia (>200 mg/dl) can be managed with small subcutaneous doses (4–10 units) of short-acting insulin.
- The recommended treatment for patients undergoing major surgery and for those with poorly controlled type 2 diabetes is intravenous insulin infusion with glucose.
Patients Treated With Insulin
- SMBG should be performed at least before each meal and at bedtime, with target preprandial values of 80–120 mg/dl and bedtime values of 100–140 mg/dl.
- Intravenous insulin/glucose/potassium should be commenced before surgery. Blood glucose levels should be monitored hourly intraoperatively and immediately after surgery. The infusion should be stopped and usual insulin treatment resumed once oral intake is established.
- An infusion rate of 1 unit/h is obtained by mixing 25 units of regular insulin in 250 ml of normal saline (0.1 unit/ml) and infusing 10 ml/h.
- Alternatively, 50 units of regular insulin is made up to 50 ml with saline and given by syringe pump at 1–2 ml/h. Adjustments to the insulin infusion rate are made to maintain blood glucose between 120 and 180 mg/dl.
- The initial insulin infusion rate can be estimated as between one-half and three-fourths of the patient’s total daily insulin dose.
- The physiological amount of glucose required to prevent catabolism in an average nondiabetic adult is ∼120 g/day (or 5 g/h), while the caloric requirement in most diabetic patients averages 5–10 g/h glucose. This can be given as 5 or 10% dextrose. An infusion rate of 100 ml/h with 5% dextrose delivers 5 g/h glucose.
- The infusion of insulin and glucose induces an intracellular translocation of potassium, resulting in a risk for hypokalemia, potassium chloride, 10 mEq, should be added routinely to each 500 ml of dextrose to maintain normokalemia if renal function is normal.
Your Questions Answered
How do you properly inject insulin?
The insulin needs to go into the layer under the skin. Pinch the skin and put the needle in at a 45º to 90º angle. Leave the syringe in place for 5 to 10 seconds after injecting.
Where is the best place to give insulin injection?
The abdomen and outer thigh are the best places to inject insulin. Other suitable areas can be the upper arms and buttock areas.
Where should you not inject insulin?
Insulin should be injected into the subcutaneous fat just underneath the skin and not into the muscle. Intramuscular injection of insulin can lead to quicker insulin action and greater risk for hypoglycaemia. The abdomen, thighs, buttocks, and upper arms are common injection sites because of their higher fat content.
Do you have to pinch the skin when giving insulin?
You do not have to pinch up the skin unless you are using a longer needle of over 6mm. Insulin shots should go into subcutaneous tissue and can be done with the needle straight in at a 90-degree angle.
Is it OK to inject cold insulin?
Although we recommend storing insulin in the refrigerator (not freezer), injecting cold insulin can sometimes are more painful. To avoid this, Insulin can be kept at room temperature, but will last approximately one month.
What happens if insulin is injected into a vein?
The effect of intravenous insulins is immediate but short-lived as it is immediately available in the bloodstream.
Does insulin cause belly fat?
Insulin can cause weight gain, not just increased abdominal fat. However, if insulin injections are not rotated and given at same area repeatedly there is risk for lipohypertrophy or lumps of fats developing.
Can a person with diabetes reuse needle and syringes?
Mostly all needles and syringes are recommended for single use. However many people reuse syringes and needles to help cut costs.
What happens if you don’t rotate insulin injection sites?
Injecting into the same spot too often can cause skin problems and can alter absorption of insulin. One can rotate to different areas on abdomen, keeping injection sites about an inch apart. Or can inject into other parts like thigh, arm, and buttocks.
Is it OK to take insulin after eating?
The newer insulins called analogue insulins act rapidly and so not advised to wait more than 15 minutes to eat after taking mealtime insulin. Rapid-acting insulins though designed to be taken right before eating, some people inject along with the meal or just after.
How do you get rid of an insulin lump (lipohypertrophy)?
Avoiding lumpy areas, if any, for few weeks/months can help get rid of lumps. (lipohypertrophy).
What angle is insulin injected?
It is recommended to inject the insulin with the needle at an angle of about 90 degrees. However, if the person is thin, then pinching the skin or injecting at a 45-degree angle is advised.
What happens if you use insulin that has been frozen?
Freezing temperature will break down the insulin and then it may not work well. If insulin is frozen once, do not use even after thawing.
Do I need to keep my insulin pen in the fridge?
Keep an insulin pen refrigerated until it is opened; after that it can be kept at room temperature.
What happens if you hit a blood vessel while injecting?
The likelihood of hitting a blood vessel in the subcutaneous fat is extremely rare. If there is blood, it is from slight bleeding after the injection and serious complications are rare.
What happens if you inject yourself with insulin and you’re not diabetic?
What happens if you accidentally inject air into muscle?
Injecting a small air bubble is usually harmless but the full dose of insulin may not be delivered as the air takes up space in the syringe.
How can I make insulin injections less painful?
The basic steps are to locate a fatty site on abdomen or outer thigh to inject the insulin, hold the needle at 90 degrees and pierce rapidly.
What is the maximum amount of insulin you can take?
Presently available insulin syringes can deliver a maximum of 100 units and insulin pen devices can deliver only 60–80 units per injection. Also large volumes can also be painful. For individuals needing high doses U300 Insulins could be tried.
Why you should not use alcohol wipe on skin prior to injecting insulin?
The evidence clearly shows there is no need to use an alcohol swab before administering an injection.
How often should you rotate injection sites?
Injection sites should be rotated with every injection. Inject at least one finger-width away from your previous injection site
Do you have to prime an insulin pen every time?
Priming means removing air bubbles and establishes that the needle is open and working, hence has to be primed before each injection.
How do you carry an insulin pen when travelling?
Put your diabetes supplies along with hand luggage as it could get too cold in checked luggage.
What happens if you hit a nerve while injecting?
Injections below the deltoid muscle can hit the radial nerve or axillary nerve and the patient will feel an immediate burning pain.
Can I put insulin back in the fridge?
Once opened, it can be stored in the fridge or at room temperature. Throw the insulin away 28 days after opening it
Have more questions?
Would you like to attend our Webinars on Insulin / Diabetes Education
We are a group of Endocrinologists in India and abroad with expertise in the management of Diabetes and use of Insulins. We understand that there are various issues for people with diabetes on insulin, particularly, with dose adjustments and diabetes control. Some are exposed to risks from hypoglycemias and even end up with medical emergencies. With this platform, we are trying to extend support to all patients and health care providers.
Vision: To support every person with diabetes on Insulin.
- To provide one stop solution for patients and professionals dealing with insulin.
- To guide with the right insulin to choose and provide support through teleconsults
- To guide with dose adjustments of Insulins remotely through chat, teleconsults etc
- To automate insulin adjustment tool and support self management of Insulin doses.
- To give information on various insulins and options available.
- To compile all brands of Insulins that are available with their costs
- To train type 1 diabetics on carb counting, insulin dose adjustments
- To support with training for insulin pump and CGMS analysis etc.
- To support pregnant women on insulin with dose adjustments
- To support diabetic patients with dietary advise
- To train healthcare providers with skills to manage insulins
- To discuss options for insulin discontinuation for type 2 diabetes.
- To support patients who are undergoing surgery, before and after.
- To support foreign nationals with dose adjustments.
- To deliver insulins through online pharmacy.
- To support COVID-19 patients needing insulin
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