Overview This has been a very common situation when, after giving adequate insulin, there has been inappropriate control of sugar. The patients in these condition blames the doctor for inaccurate treatment and doctors blame the patients for not following strict treatment regimen. But neither of the two are true in majority of cases. The real problem is most of the time overlooked which is faulty handling of insulin by patients or their care givers or sometimes even by doctors and this faulty handling is due to some misconception and common mistakes in insulin therapy.
A well known proverb says that "It is darkest below the candle". So some light will be thrown in the darkness to make it illuminated by discussing the basic misconceptions and common mistakes encountered with insulin therapy.
Mistake with the insulin vial * A common myth is that insulin must be stored in refrigerator which is not actually true. An opened vial can safely be kept at cool dark place like cupboard. Sealed vials can be stored in a bowl of water kept in a cool dark place and can be stored upto one month in room temperature.
* If a vial is kept in a refrigerator it should be never in the freezer compartment. Cold insulin should never be administered but should be brought to room temperature by rolling down between palms. An insulin pen device should never be kept in refrigeratior.
Mistake with insulin syringe * In the market insulin are available in 40 U/ml and 100 U/ml concentrations and insulin syringes are available accordingly marked 40 and 100. They should never be interchanged.
* Disposable syringes can be used 5-6 times if they are kept in good condition with caps on. Glass syringes and needle must be sterlized in boiling water before every use.
Mistake at the site of insulin injection * There is no need to sterlize the site of injection with antiseptics like spirits etc. as commonly done before any injection. Only the site should be clean. Best way is to clean the site and hand with soap and water before injection and drying them.
* The commonest mistake probably is to administer insulin at wrong site like at flexor aspects of both upper arm, inner aspects of both thighs. The recommended sites are lower abdomen, upper and outer aspect of thighs, upper and outer aspect of arms and upper side of buttocks.
* For injection site rotations, usually patients do not follow anything either they inject at the same site or inject haphazardly. Because the rate of absorption vary considerably from one body region to another, the American Diabetes Association (ADA) currently recommends rotating injection sites within body regions rather than rotating to a different region with each injection. Rotate a particular area such as left side of abdomen, injecting 1 inch away from the previous spot each time. For example , start with the left thigh until all injection spots in that area has been used. Then switch to the right thigh. By the time the patient gets back to the left thigh again the tissues are healed and ready to accept insulin again. Insulin is absorbed fastest from the abdomen, followed by the arms, the thighs and the buttocks. the ADA recommends taking this variability into account when choosing injection sites. Everybody absorbs insulin somewhat differently, so the best way to find out the effect of a given injection site is to monitor the blood glucose level frequently.
Mistake in insulin injecting technique * Commonly syringes are held in an improper way like tangentially and injected intradermally causing a bleb of insulin in the skin. Actually the syringe should be held perpendicularly to the site, a fold of skin should be taken and the needle should be inserted fully to achieve a proper subcutaneous injection.
* There is no need to rub the site injection after administration.
Mistake in timing of insulin injection
* Often erroneously insulin is given just before meals especially in hospitals and sometimes with or after meals. Actually regular or premixed insulin should be given 20 to 30 minutes before the meal and for analogues both rapid acting and premixed varity 10 minutes before the meals.
* For basal-bolus regimens the regular/rapid acting insulin (bolus) are given accordingly before each meal as prescribed and the intermediate/long acting insulin (basal)usually at bedtime or as prescribed. There is no need to take food before this basal dose of insulin.
Other mistakes in insulin therapy * There is common misconception with doctors to give subcutaneous insulin in hyperglycemic crisis as the first line of treatment. There is no such recommendation.
* There is no "Rule of Ten" in insulin therapy.
* Presently the sliding scale method used in insulin therapy is obselete.
* One myth exists that if insulin is started it cannot be withdrawn and also a myth that it is the last resort in the treatment of diabetes. This is not always true. Physicians must counsel their patients about this before giving insulin.
Conclusion This is briefly the common mistakes and misconceptions related to insulin therapy we come across day to day practice and it is our responsibility to know the basics properly and educate or guide the others to handle this essential medicine called insulin properly and wisely.