There are two main types of ‘regime’ – a basal-bolus regime or a mix regime.
The vast majority of people who are injecting insulin follow a basal-bolus regime. Basal-bolus is the term often used to describe a regime that involves taking two different types of insulin via multiple daily injections (MDI). A basal-bolus regime involves taking a long-acting form of insulin once or twice a day to keep blood glucose levels stable when you are not eating. This is known as the ‘basal’ injection.
It also includes taking a rapid-acting insulin before each meal to prevent rises in blood glucose levels resulting from eating carbohydrates or to correct elevated blood glucose levels between meals. This is known as the ‘bolus’ injection.
One of the main advantages of a basal-bolus regimen is that it attempts to mimic how the body releases insulin in people who do not have type 1. It also allows for flexibility around what is eaten and when. However, it usually involves taking between four and eight injections a day.
A ‘mix’, ‘biphasic’ or ‘twice daily’ insulin regime involves injecting a mixture of a short-acting insulin and intermediate-acting insulin twice a day – before breakfast and before dinner.
The regime means having fewer injections, but less flexibility. The regime only works for people who have three regular meals of the same carbohydrate content and at similar times every day, as well as snacks mid morning and before bed.
Cartridges vs disposables
Insulin pens can be reusable pens, where you replace a cartridge in the pen when the insulin runs out; or pre-filled disposable pens, where you simply take out a new pen when your old one runs out.
The needles used to deliver insulin injections have dramatically reduced in size. Most people with type 1 diabetes use needles that are 4mm, 5mm or 6mm long but they come in sizes up to 12mm. The thickness of needles also varies. It is important to try different sizes to see which needle is most comfortable for you.
The right pen needle
Are you having unpredictable highs and hypos? Bruises around your injection site? Insulin leaking out after you take a dose?
Or has your pen needle prescription been changed – and you’re not sure it’s for the better?
Pen needles, like lancets, are easy to take for granted. But a pen needle that’s not up to scratch (so to speak) can be a real pain. Input:JDRF has become aware of people having problems with their pen needles and we hope we can help.
The main topics to consider discussing with your GP and/or diabetes care team are:
- Needle length – pen needles come in different lengths (measured in millimetres or mm)
- Needle tip characteristics – needle points are not all created equal
- Product quality – if you get a dodgy needle, tell someone who can help
- Needle length
It’s easy to assume that people with more body fat need a longer needle to get their insulin in, and many GPs prescribe pen needles according to that assumption. Or, worse, a GP may give all their patients the same needle, even though they may have different needs.
The Forum for Injection Technique (a body of experienced UK diabetes specialist nurses) recommends:
- Children and adolescents should use a 4mm pen needle regardless of age, gender or BMI. There is no medical reason for recommending needles longer than 6 mm
- 4mm pen needles are recommended for all adults regardless of age, gender or Body Mass Index (BMI). If people need to use needle lengths over 4mm or a syringe they must use a correctly-lifted skinfold to avoid intramuscular injections..
- People new to insulin should first try using a shorter needle rather than a longer one.
Rotating your injection sites regularly means you’ll use a range of different body parts. Most of us have more fat on our tummy than on the top of the thigh. If you use a needle type that works fine for your tummy fat, but which hits muscle in your leg, your insulin might not work as expected. Injecting insulin into muscle can cause hypoglycaemia or unpredictable insulin absorption, as well as visible bruising. For these reasons, it’s best to use the shortest needle that does the job.
However, if you find a big drop of insulin on your skin after you pull out the needle, despite waiting several seconds after you deliver the dose, you may need a longer needle. If your insulin tends to leak out, it may help to deliver half your dose in one site, and then inject the other half at least 2 inches (5 cm) away. Concentrated insulin (U-200 rather than U-100) might be another option.
Have a look at the box your needles come in to check how long they are (look for a number with mm for millimetres after it). If you think your (or your loved one’s) needles might be too long or too short, ask your GP about trying different ones, or speak to your hospital-based diabetes specialist nurse and ask them to write to the GP if the prescription should be changed.
Needle tip characteristics
To make a pen needle, a thin tube of steel is sharpened to a point using a number of cuts to the metal. More cuts mean the tip is thinner and it can go into the skin more easily. The pictures below show the difference between a needle made with 3 cuts and a needle made with 5 cuts.
If your pen needles have been changed and you think the ones you used to use went into the skin more easily, ask your GP about having your previous prescription reinstated. If they say they can’t help without input from your hospital diabetes team or consultant, get in touch with your DSN and ask them to write to your GP.
As medical devices, pen needles must meet international standards. However, from time to time, a needle isn’t up to the job. It’s important to report pen needles that aren’t safe to use, or accidents that happen (like a broken needle), so problems can be addressed.
If you have a needle that’s not safe or that doesn’t work properly:
- Save it in a puncture-proof container so you can send it back to the manufacturer if they request.
- Call the manufacturer’s customer careline (which should be printed on the box) and report it
- When you have been through a whole box of needles and some were bad, contact MHRA [Be sure to state both what was wrong and the number of bad needles out of the number in the box (for example: ‘One needle bent after I used it and two needles would not screw onto the pen so I didn’t use them, out of a box of 200’)
If you regularly have problems with your pen needles and you want to switch to a different brand, talk with your GP or diabetes care team.
Technology to record when you last used your insulin pen
Did you take your lunch time injection? These great pen additions will tell you when you last used them:
Timesulin – is compatible with numerous disposable pens only
Insulcheck – is compatible with numerous disposable or re-usable pens, and
Novopen Echo – is compatible with Novo Nordisk insulins in Penfill ® cartidges
‘Smart’ pens are expected to launch in the UK later this year (2019). These will record not just when you last injected but also the actual dose you took, upload by Bluetooth to an app on your smartphone, and calculate how much insulin is still on board in the following hours. This will help you calculate whether or not correction doses are needed.
Injection ports to reduce the number of skin punctures
Cut three days of MDI down to one single skin puncture!
i-Port Advance™ is a small injection port that lets you take your insulin without having to puncture your skin for each injection. It’s easy to wear and easy to use, and both fast and long acting insulin can be injected into the same port. The port can be worn for up to three days during all normal activities, including sleeping, bathing and exercise.
User views on i-Port Advance
Andrew said “I use (i-Port Advance) because it is a lot better than taking injections every day and I like (it) because it’s pain free and I would recommend it to any one.”
Tara said “I used to use these before I got the pump, it was amazing as (it) stopped the stinging pain when I injected, and meant I could inject as many times as I liked as I didn’t need to actually inject through my skin. Between this and the Expert meter, it was the closest I could get to a pump while on injections.”
This is currently not normally available on the NHS. It currently costs £72 for a month’s supply or £15 for a 6-day sample (without VAT).
You can find more information on this at the Medtronic website.
A similar device, the Insuflon Subcutaneous Injection Port, lasts for up to five days, and is cheaper than the i-Port Advance, but may not be so convenient to use.
Jet injectors are designed to fire a very fine stream of insulin through the skin under high pressure without needing a needle to pierce the skin. Once under the skin the insulin should diffuse wider in the subcutaneous tissue than insulin injected through a needle.
The InsuJet™ system is available on prescription in the UK or directly through Spirit Healthcare Ltd.
Injex is available in the UK but not on prescription.
These needle-free injectors sound great in principle, but have not proven to be popular.
Devices to minimise the pain of injections
Cold, pressure or vibration can distract the nerve endings and minimise any pain from injections.
Buzzy – Taking the Sting out of Shots – a little device for children or adults, to minimize the pain of injections, infusion set changes, finger stick tests and blood drawing.
‘TickleFLEX Insulin Injection Aid is an accessory for the end of your insulin pen that makes self-injecting a safer, more comfortable, more consistent and worry free process.’