Getting started with Insulin Injections Table of Contents

Introduction ...... 2 Blood Glucose Levels

Insulin Injection Devices ...... 3 • Hyperglycemia ...... 15

Insulin Syringes • Hypoglycemia ...... 16 • Choosing a syringe ...... 4 General Recommendations • Preparing a dose of insulin ...... 5 • Proper needle use ...... 17 • Mixing insulin in a syringe ...... 7 s t • Proper disposal of your sharps ...... 18 n Insulin Pens e • Insulin care and storage ...... 19 t • Preparing a dose of insulin ...... 9 n Patient Information ...... 20 o Injection Technique

C • Insulin injection ...... 11 f

o • Needle length ...... 12

e • Injection sites ...... 13 l b a T

1 Introduction

This “Getting Started with showing you how to use your Insulin Injections” booklet injection device and helping you aims to help you with with your injection technique. practical information about insulin injections and good Once you are at home, refer to injection technique. It will this booklet and the notes that reinforce the information have been made to remind given to you when you were yourself of any aspect of your diagnosed or when you care. started taking insulin.

Your diabetes nurse educator I will have taken you through n

this “Getting Started with t r

Insulin Injections” booklet o

explaining your daily routine, d u c t i o n

2 Insulin Injection Devices

Each device has its own advantages and drawbacks. Ask your healthcare professional for advice on which device (pen or syringe) best suits you.

1 - Insulin syringes to be 2 - Reuseable insulin pens 3 - Pre-filled insulin pens, used with insulin vials to be used with insulin these are disposable s cartridges e c i S T 0 5 0 5 0 I N 5 1 1 2 2 3 U v e D Note: not all insulin cartridges S T I 0 5 0 5 0

can be used with all insulin N 5 1 1 2 2 3 n pens. U o S

i Some insulin treatments T I t 0 5 0 5 0

N combine an insulin pen for one c 5 1 1 2 2 3 U type of insulin and an insulin e j syringe for another type or may n

I require two insulin pens for two different insulin types. n i l u s n I

3 Choosing a syringe

Insulin syringes are available by prescription in 3 sizes: 0.3 ml, 0.5 ml and 1 ml. Choose a syringe size based on the dose (units) of insulin you require. It is easier and more accurate to measure smaller doses with a smaller volume syringe. S T

• 0.3 ml insulin syringesI • 0.5 ml insulin syringes • 1 ml insulin syringes 0 0 0 0 0 0 0 0 0 0 N

These1 2 3 4 5 6 7 syringes8 9 1 are graduated These syringes are graduated in These syringes are graduated U in 1-unit intervals and are 1-unit intervals and are ideal for in 2-unit intervals and are ideal for doses under 30 doses between 30 units and 50 ideal for doses over 50 units. S S T I T units because of their units. 0 0 0 0 0 0 0 0 0 0 I 0 5 0 5 0 5 0 5 0 N N 1 2 3 4 5 6 7 8 9 1 discrete size and easy 1 unit U 5 1 1 2 2 3 3 4 4 5 U

adjustment. I n s S S S T T T u I I I 0 5 0 5 0 0 0 0 0 0 0 0 0 0 0 0 5 0 5 0 5 0 5 0 N N N l 5 1 1 2 2 3 5 1 1 2 2 3 3 4 4 5 U 1 2 3 4 5 6 7 8 9 1 U U i n S S S T y I T 0 5 0 5 0 I 0 5 0 5 0 5 0 5 0 N i 5 1 1 2 2 3 N U n 5 1 1 2 2 3 3 4 4 5 U g e S s T I 0 5 0 5 0 N 5 1 1 2 2 3 U

4 Preparing a dose of insulin

Using proper technique to prepare an insulin dose helps ensure that you are receiving accurate insulin injections.

s Gently roll vial of cloudy Remove the white cap covering With the vial standing upright, e insulin (premixed, the plunger, then carefully insert the needle straight g intermediate- or long-acting twist and remove the orange through the centre of the n i insulin) between your hands needle cap without touching rubber cap of the insulin vial r 20 times to mix evenly. Never the needle. and push the plunger down. y

S shake. Note: Always check the label Draw air into the syringe equal This injects air into the vial, n i to the number of units of making it easier for you to l on the insulin vial for any

u special instructions and the insulin needed. draw out the insulin. s expiry date. n I

5 Preparing a dose of insulin

Hold the vial and syringe Check for bubbles. Tap Remove the needle from

upside down. Make sure that syringe. Expel any bubbles the vial and perform your I the point of the needle inside and the extra insulin. Check injection. n s

the vial is well beneath the that you have the correct u surface of the insulin. Slowly amount for your dose. Safely dispose of your l i pull the plunger, drawing the needle and syringe using n

correct amount of insulin, Note: Although air bubbles the techniques described S plus a little extra, into the are not dangerous if injected, on page 18 of this y syringe. they may affect the accuracy booklet. r i of your insulin dose. If air n bubbles remain, inject all of g the insulin back into the vial e s and start again.

6 Mixing insulin in a syringe

Remove the white cap With the vial standing upright, Draw air into the syringe equal covering the plunger, then insert the needle straight to the number of units of clear s

e carefully twist and remove the through the centre of the insulin needed. Insert the

g orange needle cap without rubber cap of the cloudy needle through the centre of n touching the needle. insulin vial and push the the rubber cap of the clear i r Draw air into the syringe equal plunger down. (rapid acting analogue or fast- y to the number of units of This injects air into the vial, acting insulin) vial and inject S cloudy (intermediate acting making it easier for you to draw the air. n the insulin out of the bottle

i insulin) needed. l later. Remove the needle u

s without drawing any insulin

n into the syringe. I

7 Mixing insulin in a syringe

When mixing two types of insulin within one syringe, it is important to draw up your clear rapid- acting analogue or fast-acting insulin before your cloudy intermediate-acting insulin. I n Hold vial and syringe upside Gently roll the vial of cloudy Remove the needle from the s down and keep the point of the intermediate- or long-acting insulin vial and perform your u

between your hands 20 times to l

needle well beneath the surface injection. i of the insulin. Slowly pull the mix evenly. Never shake. Insert the n needle straight through the centre plunger, drawing the correct Safely dispose of your needle S of the rubber cap of the cloudy amount of clear insulin, plus a and syringe using the y

insulin vial and turn it upside down. r

little extra, into the syringe. techniques described on page i

Slowly and carefully pull the n Check for bubbles. Tap syringe. 18 of this booklet.

plunger, until you have the TOTAL g Expel any bubbles and the extra number of units needed (cloudy + e

insulin. Check that you have the clear). s correct amount for your clear Note: If you accidentally draw up too much cloudy insulin, discard insulin dose. Remove the needle the mixture and begin again. Do not re-inject back into the vial from the vial. since it has been mixed with the clear insulin. 8 Preparing a dose of insulin

Not all insulin cartridges can be used in all insulin pens (please refer to the insulin manufacturer’s instructions).

Consult your manual for Quickly but gently, bend and Take off the cap of your insulin s instructions on how to properly extend your arm 20 times to pen. Screw a new needle onto n refill your insulin pen. Insert a mix insulin (premixed, your pen. e new insulin cartridge if required intermediate- or long-acting P (refillable). insulin) evenly. Never shake. n If insulin does not look i l thoroughly mixed, roll the pen u

s 10 times between your hands. n I

9 Insulin Pens 10 and safely dispose of your needle safely dispose of the and syringe using techniques described on page 18 of this booklet. Always remove the needle Always remove after each injection

your injection. m

for Set your dose using the dial and Set your dose using per op appears.

until a dr should appear; repeat this step should appear; repeat button. A drop of insulin button. A drop press down on the injection press pointing upwards and slowly pointing upwards Hold the pen with the needle Hold the pen with end of your pen, dial 2 units. end of your pen, Using the dial found on the Using the dial found Check insulin flow (prime). Check insulin flow Preparing a dose of insulin of dose a Preparing Insulin injection

Proper insulin absorption occurs when it is delivered to the fat layer (subcutaneous tissue) found between your skin (dermis) and your muscle.

Skin (dermis)

Fat layer (subcutaneous tissue) e Muscle u q i The depth of the Lifting your skin into a fold Lifting the skin may not be n

h subcutaneous tissue may be before injecting with an 8 mm required if you are using a very c different between individuals or 12.7 mm needle will help short needle, such as the 5 mm e and from one injection site to you avoid delivering insulin into pen needle. T another. Talk to your your muscle by accident. n healthcare professional about o

i the injection technique that is Use only the thumb, index and t best for you. Ask questions middle finger to perform a c and have him/her walk you correct lifted skin fold. e j through your injection n

I technique on a regular basis.

11 Needle length

Your healthcare professional can recommend a needle length and injection technique that is most appropriate for you. 5mm mini 8mm short 12.7mm original Follow these general recommendations to ensure proper insulin absorption and to avoid an intramuscular injection: Injection technique

Needle length Choose the right pen needle I

recommendations n ™ Choose the BD Ultra-Fine III Mini Pen Needle if you: j e

• want the shortest pen needle available c

5mm 90º • are muscular or have low to moderate body fat t i

without a • are selecting the pen needle for a child o

lifted skin fold • don't want to pinch up n

Choose the BD Ultra-Fine™ III Short Pen Needle if you: T e • are like most patients – it's a size that's appropriate 8mm 90º c

for many people h with a lifted skin fold n i q ™

Choose the BD Ultra-Fine Original Pen Needle if you: u

• take large doses of insulin e 12.7mm 90º • have dexterity issues with a lifted skin fold

12 Injection sites

Rate of insulin absorption varies between injection areas

Upper Arms Medium rate

Abdomen e Thighs and Fastest and most u

q Buttocks consistent rate i Slowest rate n h c e T n

o Amount and speed of absorption may differ between areas, which may affect your glycemic i t levels. Remain within one area (e.g. abdomen) as much as possible. Follow a site rotation pattern c to avoid injecting the same site too often. e j n I

13 Injection sites I n

The abdomen is the best The outer thighs and buttocks j The upper arms are the next e

area for insulin absorption. best area for insulin absorption. do not absorb insulin quickly. c

Avoid injecting within two This site is harder to reach, Exercise may affect the rate of t i inches of your belly button. which makes it more difficult to absorption. This site should o inject yourself correctly. not be used often. n T e c h n i Repeatedly using the same site for insulin injections may lead to the q u development of fatty lumps or “lipos” caused by “lipodystrophy.” e “Lipos” can be disfiguring, and may lead to improper insulin absorption.

14 Hyperglycemia

Changes and imbalances in your health, diet, exercise, or medications may cause your blood sugar levels to rise or fall. If you learn how to recognize the first signs, you can treat yourself quickly or get help before your condition worsens. Hyperglycemia (High Blood Glucose) Blood glucose levels above 11 mmol/L

s Causes First signs What to do l • Stress from an illness • Increased thirst • Test blood glucose level frequently. e v (e.g. infections, fevers) • Urinating more often • If it is over 13.3 mmol/L, test your e • Emotional stress (e.g. conflicts with • Tiredness urine for ketones. L family, problems at school or work) • If blood glucose is under 13.3 e • Pregnancy Signs of severe high blood mmol/L and there are no ketones s • Eating too much food glucose (ketoacidosis) in your urine, try exercising. o

c • Not exercising as much as planned • Heavy, laboured breathing • If ketones are present, do not u • Not enough insulin (type I • Breath that smells fruity exercise. l diabetes) • Very dry mouth • Call your healthcare professional G • Insulin is not effective • High levels of ketones in the urine immediately. d (type II diabetes) • Nausea, vomiting or abdominal • Drink fluids without sugar if you o pain are able to swallow. o l B

15 Hypoglycemia

Hypoglycemia (Low Blood Glucose) Blood glucose levels below 4 mmol/L

Causes First signs What to do B l • Not eating enough food • Sweating • Test your blood glucose level. o • Missed or delayed meal • Headache • Eat or drink a form of sugar. o • Exercising without taking • Heart beating quickly 2-3 BD™ Glucose Tablets d 3 precautions • Hunger ⁄4 cup of juice or pop G

• Exercising more than usual • Shakiness, light-headedness and 1 tbsp of honey l u • Taking too much insulin weakness • Wait 10-15 minutes, then test again. c

• Fatigue • Repeat if it remains too low. o

• Mood changes s

Tell friends and family what to e do if you become unconscious: Signs of severe low blood L glucose • Call your healthcare professional. e • Never give you fluids or food by v

• Confusion or disorientation e mouth. • l Unconsciousness s • Give Glucagon according to package • Seizures instructions.

16 Proper needle use

Use needles only once Thin-wall needle technology has made it possible to develop thinner

s needles with the same rate of insulin flow, which are easier and more

n comfortable to use. These newer needles, however, are more fragile and

o are designed for single use only. i t There are no benefits to re-using needles, only risks. a New needle Inaccurate doses: Reused needles can leak fluid or allow air into the d cartridge. This can affect the concentration of insulin and lead to n

e inaccurate doses. Painful injections: New needles have a silicone coating, which is removed m with use. Without this layer of lubrication, injection can be painful. m Broken needles: Thin needles are weakened by reuse and can actually o c Tip damage break, leaving fragments of metal in the skin. e caused by re-use

R Avoid injecting through clothes l Injecting insulin through clothing using a syringe or pen is not advised. a r • It is difficult to perform a correct lifted skin fold when injecting e through clothes. n

e • Clothing fabric removes the silicone coating and can damage the needle tip, which increases pain and discomfort when injecting. G • It is not possible to inspect the injection site for bleeding, insulin leakage or infection when injecting through clothes. 17 Proper disposal of your sharps

Contact your local garbage removal office or health department for information on safe disposal. The following guidelines may be helpful: G

Remove the needle from Put your used syringes, needles Never handle someone e your syringe or pen using a and lancets into a BDTM Sharps else’s syringe or pen needle n BD Safe-ClipTM, which stores Container or a hard plastic or unless you have been trained e by a healthcare professional in r one year's supply of metal container with a screw-on a proper injection technique, needles. lid. When the container is full, l handling methods and seal the lid securely and dispose R disposal. of it following your city’s e guidelines. c Accidental needle stick injuries o

may cause serious infections. m Keep this container away from children. m e

Do not put the filled container n Never throw used syringes, into or near your recycling bin. d syringe needles, pen a t needles or lancets in the For more information on how to i o regular garbage. dispose of syringes, needles or n lancets, call BD toll-free at s 1-888-BD-CARES (232-2737).

18 Insulin care and storage

For better comfort and insulin efficiency, take insulin out of the refrigerator at least one hour before your injection; cold insulin may sting and slows insulin absorption rates. s n Unopened insulin vials or cartridges should be stored in the refrigerator between 2ºC and 8ºC. o i Opened insulin vials or cartridges can be safely stored at room temperature for up to one month t (please refer to insulin manufacturer’s recommendations). a d Never use insulin after the expiry date and avoid exposure to extreme temperatures. n e m m o c e R l a r

e Below 0ºC Insulin is destroyed Above 30ºC Insulin’s effectiveness n begins to decrease e G

19 Patient Information

Name: Date of Birth: Address: Telephone Number: Name of insulin(s): Insulin dose: P a t i

Useful numbers e

Diabetes specialist nurse: Telephone: n t

Hospital consultant: Telephone: I n

GP / Practice Nurse: Telephone: f o

Pharmacy: Telephone: r m

Telephone: a t

Telephone: i o n

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