What are the newer insulin delivery techniques for patients with diabetes?

Newer Insulin Delivery Techniques

The shortest needles (4-mm pen needles and 6-mm syringe needles) should be the first-line choice for all patients with diabetes, as they are safe, effective, less painful, and avoid intramuscular injection regardless of age, BMI, or body type. 1, 2

Modern Needle Technology

Optimal Needle Selection

• 4-mm pen needles (32-gauge) are universally recommended as the safest option for all patient populations, including children, adults, pregnant women, and patients across all BMI ranges. 1, 2
• These ultra-short needles reliably traverse the 2.0-2.5 mm average skin thickness and deliver insulin to subcutaneous tissue while minimizing risk of intramuscular injection, which can cause severe hypoglycemia especially with long-acting insulins. 1
• 6-mm syringe needles serve as the shortest option when using vials and syringes rather than pens. 1
• Needles 6-8mm should be actively discouraged due to significantly higher risk of intramuscular injection. 2

Critical Injection Technique Updates

• Inject at 90-degree angle after lightly grasping a skin fold, then release the pinch before injecting to ensure proper subcutaneous delivery. 2, 3
• Keep the needle embedded in skin for at least 5-6 seconds after complete insulin delivery to ensure full dose administration. 2, 4
• Use a new needle for every single injection—needle reuse is directly associated with lipohypertrophy, injection pain, and bleeding. 2
• Routine aspiration is not necessary and should be omitted. 2

Advanced Insulin Delivery Systems

Insulin Pens (Preferred Method)

• Insulin pens are preferred over syringes in most cases due to simplicity, convenience, and improved accuracy. 1
• Pens are particularly beneficial for patients with dexterity issues or vision impairment, allowing accurate dosing when syringes would be problematic. 1
• Connected (smart) insulin pens represent a significant advancement, providing dose tracking, timing reminders, and data integration with diabetes management apps. 1

Automated Insulin Delivery (AID) Systems

• AID systems should be offered as first-line therapy for youth and adults with type 1 diabetes and other insulin-deficient diabetes who can use the device safely (with or without caregiver assistance). 1
• These closed-loop systems automatically adjust basal insulin delivery based on continuous glucose monitoring data, representing the most physiologically advanced insulin delivery currently available. 1

Insulin Pump Therapy

• Insulin pump therapy (with or without sensor-augmented low glucose suspend) should be offered to patients on multiple daily injections who are not able to use or interested in AID systems. 1
• Pumps can also be offered to adults with type 2 diabetes on multiple daily injections who are capable of safe device use. 1
• Continuous subcutaneous insulin infusion (CSII) provides more precise basal rate adjustments and eliminates the need for multiple daily injections. 1

Critical Site Management

Lipohypertrophy Prevention

• Lipohypertrophy distorts insulin absorption and must be actively prevented through proper site rotation—never inject into these lesions. 1
• Rotate systematically within one anatomical area rather than rotating to different areas with each injection to maintain consistent absorption patterns. 2, 3
• Visually inspect and palpate all injection sites at minimum once yearly, ideally at each visit. 1

Optimal Injection Sites

• Abdomen (fastest absorption), upper outer thighs, posterior lateral upper buttocks/flanks, and middle third posterior upper arm are recommended sites. 3
• Avoid areas with lipohypertrophy, inflammation, scarring, or active skin conditions. 3

Special Population Considerations

Pregnancy

• Pregnant women with diabetes should use 4-mm pen needles throughout all trimesters due to abdominal fat thinning from uterine expansion. 1
• First trimester: No change in technique needed. 1
• Second trimester: Inject over entire abdomen with properly raised skinfolds; lateral abdomen acceptable without skinfold. 1
• Third trimester: Lateral abdomen with proper skinfold technique; alternative sites (thigh, upper arm, buttock) acceptable if patient apprehensive. 1

Cloudy Insulin Preparations

• Roll horizontally between palms 10 times for 5 seconds, then tip 10 times for 10 seconds to properly resuspend NPH and premixed insulins. 1, 3
• Visually confirm adequate mixing—repeat if crystal mass remains visible. 1
• Vigorous shaking creates bubbles that affect accurate dosing and must be avoided. 1

Safety and Disposal

Sharps Management

• Used needles must be disposed of immediately in puncture-resistant sharps containers without recapping to prevent needlestick injuries and blood-borne pathogen transmission. 1, 2, 4
• Hard plastic containers (detergent bottles) or metal containers (coffee cans) are acceptable alternatives when commercial sharps containers unavailable. 4

Storage Requirements

• Store unopened insulin refrigerated without risk of freezing. 1
• After initial use, insulin may be stored at room temperature (15-30°C or 59-86°F) for up to 30 days or per manufacturer specifications. 1

Common Pitfalls to Avoid

• Never inject into lipohypertrophic areas—this is one of the most common errors causing erratic glucose control. 1
• Avoid intramuscular injection, particularly with long-acting insulins, as this causes severe hypoglycemia due to rapid, unpredictable absorption. 1
• Do not reuse needles despite cost pressures—the complications outweigh any savings. 2
• Do not skip the 5-6 second wait after injection—premature needle removal results in insulin leakage and underdosing. 2, 4