Tuesday 29 January 2019

"Do the Right Thing" - Getting insulin injection technique right

Well, January is nearly gone, and this is my first new blog post of 2019. It’s been a busy time for me, and it promises to be a busy year, not least in the world of diabetes which has become such a big part of my life in retirement.

One of the things that has occupied some of my time and attention this month has been starting my role with the newly re-constituted @FIT4Diabetes Board, a group of healthcare professionals who work under that banner, supported by Medical Technology Company Becton Dickinson, to promote best practice in technique and safety for those receiving and administering insulin injections.

FIT Board Members
I was pleased, but frankly somewhat surprised and flattered, when I was asked late in 2018 to join the FIT Board as a patient representative. I am aware that I am one of the longstanding members of the online diabetes patient community, known directly or online to many fellow people living with the condition; I am also aware that I have been something of a minority voice in that community as one of those happily managing their condition by multiple daily injections rather than an insulin pump. The very nature and demographic of the online world gives a false impression of the ubiquity of pump and diabetes technology use.

Moreover, I am also very aware that I am no expert in diabetes, despite my 21 years of living well with it. Indeed, I have often said that I’m not really very interested in diabetes, nor do I have any great enthusiasm for clever technological solutions. I am very interested in people, and in doing my bit to support and contribute to the greater good, and so my participation in #GBDoc is based very much on an interest in the people with diabetes, rather than the condition per se.

However, having attended the first meeting of the FIT Board, I have realised that I do have something to contribute to this group and their work. At our meeting, we started with an illustrated presentation about best practice in injection technique: not the most comfortable viewing when sitting there as the only patient accompanied by three DSNs, two pharmacists and a GP! I watched with a mixture of amusement and embarrassment as one by one, my occasional or permanent bad habits in diabetes management were exposed:

Wash hands? X.

Change needle every time? X.

Rotate injection sites? X.

Prime the pen? X.

Wait ten seconds before withdrawing needle? X.

Dispose of used needle immediately in a sharps container? X.

OK, so some of these I am better with than others, but I doubt if many longstanding PWD could in all honesty tick every single one, every single time. My excuse? Well, it’s that life gets in the way! We’re often told that diabetes shouldn’t stop you leading a full and normal life, and I have certainly lived as full and as normal a life since diagnosis as before it.

However, “normal life” is often very busy: I think back to my hectic working days as a teacher, often in work from 7:30am until 6pm, with literally no break. Lunch was often snatched on the go, and dressed in a suit, with formal shirt and tie, eating in a crowded school canteen or grabbing a sandwich during a lunchtime meeting is not conducive to good injection technique. It’s hardly easy carefully to choose the right site, prime the pen, leave it in for 10 seconds etc. More likely grab the pen - untuck shirt under table - jab - pen back in pocket with top on over needle. And all that was until very recently (with the arrival of FreeStyle Libre) preceded by a messy finger prick test!

I am also very aware that discreet and hurried injecting is, rightly or wrongly, rather easier for a man than a woman: a dress and tights, still commonly a staple of formal dress for women in the workplace, gives no opportunity for easy, dignified exposure of a suitable injection site, and it is small wonder that many women with diabetes inject through tights – far from ideal, but a pragmatic compromise.

But does it matter?

Well, since my watching that awkward presentation at the FIT meeting, I have to say yes. Confession time: I have become very aware that the flabby bits above my waistline are not just a touch of middle-aged spread, but actually a textbook example of Lipohypertrophy, lumps under the skin caused by accumulation of fat cells at the site of insulin injections. Not life-threatening, far from the worst of the secondary issues which can arise from living with diabetes, but nevertheless  a very real and creeping threat to living well on insulin injections.

I wonder whose tum that is?? !!
Lipos develop because of poor site rotation over the years, and injecting into them significantly reduces the effectiveness of insulin, caused by irregular and incomplete absorption rates. Since that meeting two weeks ago, I have been carefully avoiding those over-used sites, and guess what? My insulin requirement has fallen, quite significantly!

I genuinely think that Lipohypertrophy is the Cinderella of diabetes issues. We PWD are all so bothered about avoiding hypos, dealing with the uncomfortable highs, pursuing elusive “flat lines”, over-reacting to the TMI that many of us now get from our Libres and CGMs, that we overlook the insidious damage that we are doing to our too-easy-to-reach tummies.

And judging by the responses to a quick Twitter poll that we did after the meeting, checking our injection sites and advising on injection technique are a frequently missing part of our consultations with HCPs in clinic.

Perhaps it’s time we all started to think rather more about injection technique, site rotation, size of needles etc. I spent the first 20 of my 21 years with diabetes using the 8mm needles that were the norm back in 1998, blissfully unaware that current thinking among experts is that 4mm are best for everyone, regardless of their BMI. And whilst my eyes are screened annually, my feet jabbed at every visit, questions asked about my “control”, my highs and lows, my erectile functioning, etc., nobody has ever asked about, let alone examined, my (frankly rather unattractive) midriff.

So please look out for tweets and posts from my wonderful colleagues on @FIT4Diabetes. They have been brilliant in not making me feel guilty about my own shortcomings in technique, but I have to say that, thanks to them, I’m going to try very hard to Do the Right Thing.

There you go, a title for this post  - from a song, as always: a classic from the heyday of Mick Hucknall’s Simply Red. Click on the title and enjoy a bit of 90s nostalgia, then sing it to yourself while you inject.

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