Please sing to the tune of "How do you like your eggs in the Morning?"

Question- "What do you do with your pen device in the morning?"

I presented on new injection device guidelines at a medical meeting last week. Us docs love to give people the 'third degree' about doses, carb counting, exercise etc., but in my view we have been slow to think about the 'mundane' issues of needle re-use, needle length, proper rotation of sites [i.e. not just randomly moving], injection technique, how long you hold it in, lipos at injection sites and so on. After discussing this with some diabetes nurse colleagues, I thought I would begin to explore these issues with the people with diabetes I meet in consultations.

One week on, to my surprise the great majority of people I have met and asked very honestly tell me that they regularly
-reuse needles, sometimes for 5+ injections
-leave the needle on the pen (insulin was dripping from the needle and bubbles had got into the insulin chamber) between injections
-do not rotate injection sites (but do pick a new random site each injection)
-continue to use lipos, even when they know what they are and acknowledge that the lipo may stop insulin getting in well
-hold the pen in for 2-3 seconds max

I seem to have 'kicked a hornet's nest', since even though people are very open about what they do with their pen device, I have found it very hard to persuade people to change. One patient accused me of being in the pocket of the pharmaceutical industry by suggesting he change needles each injection! A handful of these folk are DAFNE grads who acknowledge these issues were discussed on the course.

I had the feeling I was straying into sensitive territory, and I couldn't understand why that is.

So I need your help!

Are these fair subjects for discussion in a consultation?
Do your diabetes teams discuss these issues with you?
Do people with diabetes find these questions sensitive? If so, why is that?
How should us docs approach a person who is not using their pen device well, and try to persuade them to make some changes?

When I understand the issue better, I'd like to have a go at making some educational material, written, video etc. in case it may help. Anyone know of anything out there 'off-the-shelf'?

To answer my original question- "I like mine with a kiss!"

hey I'm getting into this. 2 posts in as many days after a weak or more of just reading

I think it'd be great if my consultant bothered to talk to me about these things. For 12 years I've been scared to ask about rotating injection sites because when I've tried I've been looked at like an idiot or given a book for 3 year olds which mentions its important but gives no actual tips/guides. I've even been told (while laying in hospital with DKA) that I'm over-doing my stomach injections and that the skin is "obviously" too hard & lumpy when it felt normal to me before & after said advice but the Dr rushed off before I could ask for more information.

I did used to re-use needles but mostly out of being disorganised & not having the new needles readily available whereas now I've read a leaflet (while waiting to see the Doc at a check-up) that explained how important it is & sorted out a place with ready access to the needles as soon as I got home - though actually when I go out I might still use a needle twice or maybe three times because of the hassle of finding somewhere to put a used needle. storing a replacement is easy enough but finding somewhere safe to put the original just isn't particularly easy in my experience. I do like the finger prick needles i use now which come in a set of 6 somewhat like a gun barrell so I only need one & it'll last for a day or more. Not sure if an injection needle could work in this way though.

Needle on the pen - pretty much links to above answer I guess.

Rotate - already mentioned

what's a lipo? lol

and 2-3 seconds max?! I was specifically told to hold it in at least 6 seconds & that's what I've been doing for years. Scared now.

I also imagine many people find it tough to get their GP to allow them enough needles for the amount of injections we (probably) each do these days. Everything on a prescription seems to come with an "as little as possible" idea in my experience (though my GP's actually brilliant with everything - just a shame she doesn't deal with my repeat prescription orders & is often baffled when I mention that others have cocked it up)

I just noticed you also asked "Do people with diabetes find these questions sensitive? If so, why is that?"

I'd say no-one wants to hear that they're doing it wrong when for the most part diabetics I've met have been told "here's some needles, you have to do injections with your meals" and that's it. By this I mean that several diabetics seem to have been left to work it all out for themselves so it could appear to be a more personal than intended dig when you tell them they're wrong. You've probably noticed from my earlier answers that I'm seeing things (eg lipos) for the first time here so there's definitely a lack of information being handed out.

"How should us docs approach a person who is not using their pen device well, and try to persuade them to make some changes?"

I can only answer this for how I would like to be taught & that would be to not rush to "omg! if you carry on like this you'll be dead by the end of the month" and more of a sensible explanation of what exactly I'm doing wrong & why its wrong & what to do about it. Again I find that the consultants I see just rush to get me out again & would more often go for an answer of "ask the Diabetes Nurses" than doing anything themselves.

Hope this has helped & I aplogogise if its lengthy & rambly

edit: forgot the whole true point of the topic for a second there...Scrambled!! & with ham & cheese or not at all!

I am afraid I am one of those that only change the needle bit when I change the vial - suspect that this goes back to the time when the insulin was free but the needles you had to pay for. I know and understand and accept all the arguments for changing them after every injection but it is a habit (and I am lazy) that I just can't stop.

I do change my sites but I must admit in a random fashion - I used to only use the side of my leg, as there was no fat what so ever on my stomach (this started 20 years ago) and the syringes hurt a lot in the stomach, obviously with the passage of time there is now fat on my stomach and I can use it and so I do vary now between the stomach and leg, and also move around these sites - but not in a systematic way.

I think these subjects are for discussion and should be discussed, they are with me, but as my HBA1c results have always been very good (have been down to 5.9, currently 6.2, and never higher than 7), the team have never pushed too hard to make me change as clearly what I am doing is working.

I don't know why people are sensitive about it though.

Hi,
I think they are fair questions but it is difficult to change a practice when you know you have no problems doing it the old way. I used to change syringes every time (in the olden days) and it was a "burden" to take stuff with me (where do you dispose of the syringe etc). Then the pens came in and I only change needles when the pen is empty! (lantus up to 9-10 injections) and the novorapid when the pen gets blunt or when I think of it...whenever). For me it is not a question of cost...it is convenience...so much easier to just throw the pen into the handbag sidepocket without all the other diabetes stuff. Similarly with the meter just throw it in. Use the lancet multiple times also. I have never had a problem. I would need to be persuaded that there was some advantage to me to change. Lantus tends to go in the abdomen (more because of the clothing I am wearing at the time) and novorapid in the stomach. Hey, but no hard and fast rules. I have no lipos and I hold the pen in for longer if I am out...probably because i don't want a blob of blood on clothing!

I only know one diabetic who is changing needles etc, using alco wipes etc all the time the rest fall somewhere between me and him. It is a topic we discuss. A few admit to lying because we know what you want to hear! Another topic is where do you carry all the gear. The best I have seen is a zippered carryall about 20x15x3 cm but that does not fit in a pocket and takes up a fair amount of space in a handbag. Good for travelling though. Pragmatics!
Good luck.

Sunny side up!

Helen

"what's a lipo? lol"- so sorry to go all jargonistic on you David- a rubbery lump under your skin at injection sites, which stops insulin getting in reliably.

One of the telling stats from a large international patient survey was that 75% of those not rotating got them, but 25% of those doing it all perfectly still got them... clearly we still don't know enough about why they happen, despite many theories.

I certainly understand and empathise with the comments re habit, ease, familiarity, "laziness"! Plus I can see the "if it ain't broken" approach is appealing.

What I don't know is how much of a difference these factors can make in the average person, but from my experiences I believe it can be dramatic in some.

I imagine many docs feel uncomfortable discussing these 'nitty-gritty' components of care, after all, you guys know much more about this than we do... !!! LOL

"a rubbery lump under your skin at injection sites, which stops insulin getting in reliably. "

cheers for the reply - so is this part of injecting the same spot too often?

Have you asked about "priming"? You may get some surprises there also!

I only change the needle once the insulin is depleted or if it gets sore, its bad I know, but its habit (cost effectvie)...lol

I have had no problems with lumps, or at least any that I have noticed as i do rotate, randomly, on my legs, arms, stomach and bum...

And commenting on the point Helen brought up, I do prime every injection, this is a habit I picked up from DAFNE, more often than not, before the priming, I always used to get a misfire with the injection.......but then you dont want to re inject as you cant be sure if you got the dose or not...

Are these fair subjects for discussion in a consultation?

Hell yes. You're there to help the patient and educate them to a certain degree.

Do your diabetes teams discuss these issues with you?

Yes, and on that note, I'm thankful. I change my pen needle every time now!

Do people with diabetes find these questions sensitive? If so, why is that?

Yes because diabetics take pride in their control. If someone - even another diabetic in a very similar boat - can easily offend a diabetic by suggesting they change something.

For example, I've suggested that a diabetic try adopting the DAFNE regime in the past and what sort of response did it lead to? Her saying to others that I was accusing her of not looking after herself properly without a mention of the term DAFNE in her explaination.

Wow, thanks for listening to me properly. T_T

How should us docs approach a person who is not using their pen device well, and try to persuade them to make some changes?

I'm sure you do it fine, but be prepared for some diabetics to be more awkward or bull headed than others.

I would just like to add, thank you for rasing these issues and please feel free to do so on our site. I think challenging people to change is a good thing and is one of the key things for DAFNE i.e change the the perception that Diabetics cannot eat certain things, do certain things.
I agree we can all get set in our ways and find it hard to kick habits but with encouragement we can.
I am pleased that someone from the HCP side is again being so pro-active, it helps dispell the idea that some have that the medical profession are all people that don't understand diabetics. I'm not referring to people on this site, before people get upset by my comments !
Brum_taffy are you involved in the DAFNE programme ? I only ask because it would help to have you 'labelled' on the site as a HCP, however I guess I can only do that if you are invovled in DAFNE, unless of course I get permission from the DAFNE programme people to make you a HCP. The reason for needing permission is the access to some of the parts of the site that only DAFNE HCP's have.
The more HCP's we have contributing the better, especially in the 'Questions for HCPs' forum where people often ask Diabetes related questions and having a Diabetes expert rather than other Diabetics answer is often more re-assuring.