Getting Up to Speed on New Injection Guidelines (Part 2)

Last week I mentioned that there are new insulin injection guidelines (as of 2010) that came out of a workshop called TITAN. These guidelines are important because they aim to achieve clarity about and consistency in how people with diabetes inject their insulin. Sadly, however, I suspect that not many health-care professionals, let alone people with diabetes, are familiar with these guidelines.


As a person with diabetes who injects insulin (or will be injecting insulin in the future), you need to rely on your physician or diabetes educator to use the proper technique for everything diabetes-related: blood glucose monitoring, injecting insulin, counting carbs, etc. But the reality is that this doesn’t always happen, and that means that YOU need to be updated and familiar with the latest and greatest.

This week, I’ll share some of the key recommendations to come out of this TITAN workshop. Hopefully none of these are too surprising. If they are, talk to your doctor or educator. You can actually help them get up to speed by mentioning these guidelines.

So, here’s what to know:

Shorter pen needles are fine. Pen needles come in standard lengths (8 millimeter, or mm, and 12.7 mm). But there’s no real reason to use these length needles specifically. Any adult, regardless of body size can use a shorter needle, meaning a 4-, 5-, or 6-mm needle. If you’re worried that you carry extra weight and that the needle won’t be long enough, don’t. Skin thickness is pretty much the same among all adults, regardless of body fat, body weight, or gender. Remember that the needle injects through the skin layer, and shouldn’t be injecting into muscle. And studies back this up. There’s no evidence that shorter needle use among heavier folks causes insulin leakage, scar tissue build-up, or altered insulin absorption.

So if you cringe when using a longer needle, ask your doctor or educator if you can switch to a shorter one. If you use a longer needle and you don’t mind it and have no issues with it, that’s fine. Also, I should point out that insulin syringe needles only come in the longer lengths (8 and 12.7 mm). That’s because the needle has to be long enough to plunge through the rubber stopper on the insulin vial.

No need to pinch an inch. Were you taught to “pinch up” when you inject insulin? If you’re an adult (and I’m assuming most of you are) and you use the shorter pen needles that I mentioned above, you don’t need to pinch up when injecting. This is good news because if you like to inject into the back of your arm, you probably know how hard it is to pinch up at that site. Most people need to push their arm up on a chair to be able to inject, and that’s awkward. If you’re using a longer needle (8 or 12.7 mm), however, you should pinch up when injecting to avoid injecting into muscle. Also, very thin people, children, and pregnant women may need to pinch up as well. By the way, if or when you do pinch up, the proper way is to grasp the skin with your thumb and index finger. Avoid using your whole hand to limit the risk of grabbing some muscle (injecting into muscle can be painful and may affect insulin absorption).

Rotate your sites. If you’re a farmer or like to grow a vegetable garden every year, you know about rotating crops. You should do the same with your injection sites. Repeatedly injecting into the same site day after day may seem quick and easy, but you run the risk of developing lipohypertrophy, which is a build-up of fat that can cause a lumpy appearance. Lipohypertrophy isn’t all that attractive, but more importantly, injecting into this type of tissue can greatly affect how your insulin is absorbed which, in turn, can affect how it works in the body. So, your diabetes control may be worsened.

The injection sites are: back of the arms, the abdomen, the upper buttocks, and the upper, outer thighs. One way to rotate is to use a different site for a different time of the day (for example, use the arm in the morning and the thigh at bedtime). Or, choose one site, such as the abdomen for, say, a month, but rotate within that site. Ask your diabetes educator if you need help with choosing sites. And it’s a good idea to have your doctor or educator check your sites periodically to look for signs of lipohypertrophy.

Pain, pain, go away. Insulin injections shouldn’t be painful. Really. With today’s thinner, shorter needles, giving an injection should hurt way less than lancing your finger to do a blood glucose check. If you have pain, it’s a sign that something is wrong. Here are some factors that may making injection painful:

• Using alcohol to clean the site. Alcohol can cause stinging. You don’t need to use alcohol, but if you do, let the site dry completely before you inject.

• Injecting cold insulin. Let your insulin warm up to room temperature before injecting.

• Injecting air bubbles. Air bubbles in your insulin aren’t harmful, but they can cause discomfort and also mean that you’re not getting your full insulin dose. Get rid of them.

• Reusing needles. Needles start to become dull even after one use.

• Using bent needles. Ouch! Don’t use them.

• Using needles that are too long or too wide. Ask your doctor or educator about switching to a shorter, finer needle.

• Tensing up before injecting. Relax!

If you take insulin, it’s a good idea to review your “injection technique” periodically with your educator. You can always learn something new and injections may be all that much easier for you.

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  • Ellen

    I have followed the guidelines, leave insulin out, move the site, use short new needles and still have pain about half the time. I also find large black and blue marks. Any suggestions? I only use 10 units once a day from the pen.

  • riva

    I often read injecting in your abdomen gets absorbed faster. But then I’ve also read with today’s insulin analogs that’s not true anymore. Can you clarify: does where you inject affect the time it takes your insulin to start working?

  • acampbell

    Hi Ellen,

    As you wrote, I assume that you aren’t using alcohol to clean your site and that you’re not repeatedly re-using your pen needles. That being said, I checked with a nurse colleague of mine. She advised not moving the needle when it’s in the skin, if you pinch up, to release the pinch before taking the needle out, and not pushing the needle in too hard. You might consider meeting with a diabetes educator and ask him or her to observe your injection technique. Sometimes it helps to have another set of trained eyes to pick up on anything else that could be causing the problems.

  • acampbell

    Hi riva,

    Where you inject can affect the absorption of the older insulins, Regular and NPH. With both of these insulins, absorption is quicker from the abdomen, followed by the arm, thigh, and buttocks. But with four of the newer insulins (glargine, aspart, glulisine, and lispro), absorption doesn’t appear to be affected by injection site choice all that much. Nevertheless, other factors can affect insulin absorption, including temperature, physical activity, massage, smoking, fatty tissue build-up, and size of the insulin dose.

  • Belinda

    I only use alcohol to wipe off the insulin vial, I rotate injection sites. and I hold the Lantus vial in my hand for 20-20 minutes to warm it up, after taking it from my bathroom cabinet. Yet, I frequently experience a strong burning sensation and pain when injecting Lantus. No one seems to be able to help me. Any suggestions?

  • acampbell

    Hi Belinda,

    Lantus is more “acidic” than other insulins due to its low pH. As a result, it’s not unusual for it to sting when it’s injected. Some people find that making sure it’s at room temperature, injecting into “lower” sites, like the thighs or buttocks, and injecting slowly helps lessen the sting. Otherwise, there may not be much else you can do. If it’s very bothersome, you might ask your provider to switch to Levemir (detemir).

  • Scott The Grilla

    Hello Amy,
    I work 12hr. shifts in a manufacturing plant. We only get a half hour lunch. Here’s my routine: throw my food in the microwave, go to a computer desk that is in a private cubicle, check my sugar levels, shoot 10u of Byetta into my abdomen, then retireve my food. Then I take my meds prior to eating. The reason i go to the kiosk to shoot up is because I consider other’s “feelings” while doing so. Plus, i don’t want everyone to know I have Diabetes either. (I have told quite a few though.)So this all takes roughly 10 PRECIOUS minutes.
    So my question is this, I wear Dickies worksuits at work. If i were to start injecting thru my pants into my thigh, could there be issues using the shorter needle and the Dickies material? Knowing this would give me a couple of extra seconds to actually enjoy my lunch instead of inhale it. LOL

  • Scott The Grilla

    I might also add that I inject 100u of Lantus before bed. I used to get some minor burning while trying to inject the entire amount in the same site all at once. So I heard somewhere that it was a good idea to inject half in one location and then the remainder in another location. This works great for me. Just sharing the info. Thanks.

  • Belinda

    Hi Amy – I saw my doctor last Friday, and he switched me from Lantus to Levemir as you suggested. I’m now pain free, for the first time in six months – thank you, thank, you!!

  • acampbell

    Hi Scott,

    As convenient as it would be for you, I’d recommend not injecting through your worksuit. I suspect that the material is pretty thick and with shorter needles, you can’t be guaranteed that you’ll get your full dose. Can you roll up your sleeve and inject into your arm? If not, here’s another thought, although it might seem strange: If you usually inject into your thigh, could you have an slit (with a flap) sewn into your pant leg that you could quickly open up to give the injection? It would save you time and you’d be assured of getting your full dose. But, like I said, that’s just a suggestion!

  • acampbell

    Hi Belinda,
    Great news! I’m glad the switch worked out for you!

  • pbureau

    Hi Scott,

    Do you know they have a once a week form of Byetta now called Bydureon. Talk to your physician about it.