By: Scott M. King
I appreciate the many letters we received about my February 2005 column. It’s great to have a good debate every now and then.
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I am so happy to see such a realistic set of random shots in your “My Own Injection” column of the February 2005 issue.
Having had diabetes for the same length of time as you, when I was still on shots (been pumping for a while now) I used to (a) not have alcohol prep pads with me (b) would shoot through my jeans and (c) use syringes more than once, although I used to try to use one per day before starting fresh again.
I know you will get some flack from readers. I am not so sure I could have been so honest myself, so I tip my hat to you.
Your magazine is the most realistic one that I have found, and I look forward to so many of your articles.
Keep up the good work.
New York, New York
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We are writing in regard to “My Own Injection” in the February 2005 issue of Diabetes Health. While we realize that you have dealt with diabetes for 30 years and have found your own ways to make the process easier, we are concerned that patients who read your column will adopt procedures that are not recommended.
As two diabetes educators and a pharmacy student, we have found several statements in your article that concern us. If a new insulin patient were to read your article and followed your procedures, we feel they would not be taking the best care of themselves.
While your method of separating the insulin into different containers makes it easier for you, storing insulin in a cartridge is not recommended. The cartridges are to be used in insulin pens, not with a syringe, which can result in air bubbles and contamination.
Stating that you reuse syringes implies that this is acceptable practice. Insulin syringes are designed for one use, after which they should be discarded.
Insulin needles are fine gauge and reuse damages them. Not only do they become duller, they break down, which increases pain and injury to the tissue at the injection site. Reusing syringes also increases the risk of contamination of the insulin in the vial and accidental exposure to bodily fluids.
Injecting the insulin through your jeans reduces the likelihood that the insulin reaches the subcutaneous layer. Syringe needles must enter at least 3 mm into the skin to reach the proper area. The shortest syringe needle is 5 mm, so injecting this through a thick material like denim increases the chance that the insulin is not getting to the proper location.
Patients should also be aware that if they are prone to hypoglycemia they need to carry actual glucose tablets, not Smarties, which were shown in the photo.
We were also concerned that patients may feel the need to carry their Lantus insulin with them at all times. This is a bedtime-dosed insulin, and patients should store it at home in their refrigerator until their dose is due. By carrying it around in a pack close to the body, it increases the environmental temperature and shortens the life of the drug.
We realize that you intended to describe your experience with insulin therapy; however, we do not feel that this is a good example to set for patients who read your magazine.
Tiffany Sturm, PharmD, CDE
Barbara Loehr, RPh, CDE
Christina Herrin, PharmD candidate
Medical Center Pharmacy
Shawnee Mission, Kansas
Scott King’s reply
I take Lantus two times per day, as many others do—especially type 1s—for better round-the-clock coverage. If I didn’t carry it with me, I might miss my dinner injection. You probably know that one medicine does not work the same for all people.
Smarties are mostly glucose (dextrose); the small rolls have 5 grams of carbohydrate, 4 grams of it as pure glucose (dextrose), making them a cheaper alternative to commercial glucose tablets. But since they are considered by others to be candy, I keep them in my pack with my diabetes supplies so they will be available to me when needed in cases of hypoglycemia.
Some Need Lantus Twice A Day
Charles Raine III, MD, a diabetologist in Orangeburg, South Carolina, told Diabetes Health in March 2003 that Lantus is a great basal insulin for about 80 percent of the people who take it.
“In the other 20 percent it drops off in 15 to 18 hours,” says Raine. “We are using it twice a day in some people.”
I have always liked reading your column, because you are very candid and honest. But in the February issue, when you wrote that you reuse syringes, it unnerved me. Syringes these days are so thin and they grow dull so quickly.
Dispose of used syringes when you get home. Have another bag with new syringes. That way, they don’t get mixed up. The used syringes cannot be used again.
Both my husband and 10-year-old son carry a pack similar to yours.
Thanks for telling everyone about the practical side of diabetes.
Editor’s note: Below is the American Diabetes Association’s position on syringe reuse, as it appeared in the 2004 Clinical Practice Recommendations.
Manufacturers of disposable syringes and pen needles recommend that they only be used once. One potential issue, which arises with reuse of syringes or needles, is the inability to guarantee sterility. Most insulin preparations have bacteriostatic additives that inhibit growth of bacteria commonly found on the skin. Nevertheless, syringe or needle reuse may carry an increased risk of infection for some individuals. Patients with poor personal hygiene, an acute concurrent illness, open wounds on the hands or decreased resistance to infection for any reason should not reuse a syringe or pen needle.
Another issue has arisen with the advent of newer, smaller (30 and 31 gauge) needles. Even with one injection, the needle tip can become bent to form a hook, which can lacerate tissue or break off leaving needle fragments within the skin. The medical consequences of these findings are unknown but may increase lipodystrophy or have other adverse effects.
Some patients find it practical to reuse needles. Certainly, a needle should be discarded if it is noticeably dull or deformed or if it has come into contact with any surface other than skin. If needle reuse is planned, the needle must be recapped after each use. Patients reusing needles should inspect injection sites for redness or swelling and should consult their healthcare provider before initiating the practice and if signs of skin inflammation are detected.
Before syringe reuse is considered, it should be determined that the patient is capable of safely recapping a syringe. Proper recapping requires adequate vision, manual dexterity, and no obvious tremor. The patient should be instructed in a recapping technique that supports the syringe in the hand and replaces the cap with a straight motion of the thumb and forefinger. The technique of guiding both the needle and cap to meet in midair should be discouraged, because this frequently results in needle-stick injury.
The syringe being reused may be stored at room temperature. The potential benefits or risks, if any, of refrigerating the syringe in use or of using alcohol to cleanse the needle of a syringe are unknown. Cleansing the needle with alcohol may not be desirable, because it may remove the silicon coating that makes for less painful skin puncture.
MD Says No to Injecting Through Jeans
Thank you again for all you do and for sharing about your diabetes.
I do have to disagree with giving the Lantus shot into the leg through your jeans. (You would guess I’m primarily objecting to giving the shot through the jeans, but it is even more so due to the location!)
Anders Frid, MD, from Lund, Sweden, has done some nice studies of injection sites. He states that the only two areas where you can be certain the injection is going into subcutaneous fat (and not muscle) are the buttocks or the very central abdomen. He also notes that a peak can occur from Lantus when it is accidentally injected into muscle.
H. Peter Chase, MD
Author of “Understanding Insulin Dependent Diabetes”
Editor’s note: We are summarizing below an article we ran in the May 1997 issue of Diabetes Health that addresses the topic of injecting insulin through one’s clothing.
The Gift of Jab
By Rebecca Borlaug
Injecting insulin through clothing has apparently become a sore subject among people with diabetes, who are just now learning the benefits of this relatively new practice.
Diabetes Health recently added fuel to the fiery debate. In the January 1997 issue, publisher Scott King responded to a reader’s concerns about injecting in public. King said that even before the procedure was sanctioned by any clinical trials, his own method of choice was to inject right through his jeans or shirt.
“It is doctor-approved,” he wrote, “and very quick.”
Leo Hutter of Florence, Oregon, was outraged by the recommendation. “Injecting through your clothing is about the most idiotic idea I’ve ever heard,” he wrote. “If my doctor told me that it was okay, I would have to send him or her packing posthaste.”
The doctor approval King described came from the late Peter Forsham, MD, of the University of California in San Francisco. Forsham had diabetes for 71 years and had a very distinguished career in diabetes research before his death at age 80. Forsham regularly injected through his clothing and was not afraid to recommend this procedure to others, privately or publicly.
Forsham was not alone. Once the dialogue was started on the pages of Diabetes Health, reactions have continued to pour in.
Frances Seikaly of West Bloomfield, Michigan, has been practicing intensive therapy and injecting through her clothes for seven years. She has injected through all types of materials, including leather pants. “I have never had an infection or site reaction,” she writes. “The only drawback is if the article of clothing is light colored and I experience a ‘bleeder’ (an occasional small spot of blood that appears when the needle is withdrawn).”
Perhaps more convincing are the results from a clinical study published in the March 1997 issue of Diabetes Care. The study assessed the possible risks or benefits of injecting through clothing. The study was initiated by George Grunberger, MD, from Wayne State University in Detroit, Michigan, whose interest was sparked after seeing a colleague inject insulin through his pants. Unaware of this practice, Grunberger’s colleague informed him that he was not the only person using this technique. After questioning some of his patients, the director of the diabetes clinic at Wayne State University found his colleague was right. Many people on insulin were injecting through their clothes without their doctors’ okay.
Study participants were instructed to use their thighs for the injection site. Those injecting through their clothing were given a list of fabrics—cotton, denim, polyester, wool, silk, nylon, Lycra, rayon, flannel, linen—that could be worn during the injection. They were taught the signs and symptoms of infection and were told to notify the investigators immediately if they suspected any infection. They were also given weekly log sheets to record information such as benefits, problems and the type of clothing the injections were given through.
Of the 7,275 injections administered during the study, there was no clinical indication of infection when injections were given through clothing. In addition, the study indicates that a significant number of subjects reported that the technique made injecting easier and more convenient.
According to Grunberger’s study, injecting insulin through clothing is safe, convenient and can simplify an already complex diabetes regimen.
“We are trying to do away with as many excuses as possible,” says Grunberger, referring to those who complain of being too busy to take their insulin. “The transportation of equipment and medications, and the need to find a private location to partially disrobe, make the regimen particularly obtrusive.”
Type 1, 30 years (and counting)
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