‘ASSESS PATIENT’S TECHNIQUES AND KNOWLEDGE TOWARDS INSULIN PEN INJECTION AT OUTPATIENT PHARMACY IN HOSPITAL SULTANAH NORA ISMAIL,

BATU PAHAT.’

PREPARED BY: MUHAMMAD ARIFF B. MAHDZUBDIPLOMA IN PHARMACY

UNIVERSITY TEKNOLOGY MARA (UiTM)

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Absolute lack of insulin Relative lack of insulin

Type I DM Type II DM

HYPERGLYCEMIAHYPERGLYCEMIA

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InsulinInsulin OHAOR

OHA + InsulinInsulinOR

InsulinInsulin*DM = Diabetes Mellitus OHA = Oral Hypoglycaemic Agent

Figure 1: Prevalence of diabetes among Malaysians above 30 years old from 1960-2006 [1]

31. Letchuman GR, Nazaimoon WMW, Mohamad WBW, Chandran LR, Tee GH, Jamaiyah H, Isa MR, Zanariah H, Fatanah I, Ahmad Faudzi YA. Prevalence of diabetes in the Malaysian National Health Morbidity Suevey III 2006. Med J Malaysia 2010; 65(3): 173-9.

Target subcutaneously

determine its effectiveness in glycaemic control [2-4].

Patient education is crucial to achieve desired glycaemic control.

Variability in patients’ understanding and practice result in different therapeutic outcome.

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2. Strauss K, Gols HD, Letondeur C, Matyjaszczyk M, Frid A. The second injection techniques event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int. 2002; 19(1): 17-21.

3. Partanen TM, Rissanen A. Insulin injection practices. Pract Diabetes Int. 2000; 17(8): 252–4.4. Strauss K, Gols HD, Hannet I, Partanen TM, Frid A. A pan-european epidemiologic study of insulin injection techniques in patients with diabetes.

Pract.Diabetes Int 2002; 19(3):71-6.

LITERATURE REVIEW

• Insulin injection technique determines the effectiveness of insulin[5].• Incorrect insulin pen injection technique may lead to uncontrolled blood glucose

and may cause undesirable complications such as pain, bleeding, bruising and lipodystrophy [3,5].

63. Partanen TM, Rissanen A. Insulin injection practices. Pract Diabetes Int. 2000; 17(8): 252–4.5. Dunning T et al. Insulin delivery devices. Australian Prescriber 2002;25:136-138.

• Resuspend isophane insulin (NPH) and premixed insulin before injection [2].

• Inadequate insulin re-suspension was proportionately correlated to the frequency of hypoglycaemic attack, thereby affecting diabetes control [6,7].

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2. Strauss K, Gols HD, Letondeur C, Matyjaszczyk M, Frid A. The second injection techniques event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int. 2002; 19(1): 17-21.6. Jehle PM, Micheler C, Jehle DR, Breitig D, Boehm BO. Inadequate suspension of neutral protamine Hagedorn (NPH) insulin in pens. Lancet 1999; 354 (9190):1604–1607.7. Jehle PM. Pens: Richtige Mischung = weniger Unterzuckerungen. Diabetes J 2000; 5: 46–50.

To increase the chance of subcutaneous injection [4,8].

Strauss et al reported that pinching up method and dwell time of needle under the skin were associated with improved HbA1C [4].

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Figure 2: Correct (left) and incorrect (right) ways of performing skin-fold. Adapted from New Injection Recommendations for Patients with Diabetes, 2010 [7].

4.Strauss K, Gols HD, Hannet I, Partanen TM, Frid A. A pan-european epidemiologic study of insulin injection techniques in patients with diabetes. Pract.Diabetes Int 2002; 19(3):71-6.8. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J. et al. New Injection Recommendations for Patients with Diabetes. Diabetes & Metabolism 2010, 36: S3 -S18.

Well absorbed into abdomen, followed by upper arms, thighs and buttocks.

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8. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J. et al. New Injection Recommendations for Patients with Diabetes. Diabetes & Metabolism 2010, 36: S3 -S18.9. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, Letondeur C, Sauvanet JP, Tubiana-Rufi N, Straus K. The Third injection Techniques Workshops in Athens (TITAN). Diabetes and Metabolism 2010;36:19-29.

Figure 3: The recommended insulin injection site (coloured-area). Adapted from New Injection Recommendations for Patients with Diabetes, 2010 [8].

To prevent

lipodystrophy lipohypertrophy lipoatrophy.

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4.Strauss K, Gols HD, Hannet I, Partanen TM, Frid A. A pan-european epidemiologic study of insulin injection techniques in patients with diabetes. Pract.Diabetes Int 2002; 19(3):71-6.8. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J. et al. New Injection Recommendations for Patients with Diabetes. Diabetes & Metabolism 2010, 36: S3 -S18.10. Young RJ, Hannan WJ, Frier BM, Steel JM, Duncan Leslie JP. Diabetic lipohypertrophy delays insulin absorption. Diabetes Care 1984; 7 (5).11. Thow JC, Johnson AB, Marsden S, Taylor R, Home PD. Morphology of palpably abnormal injection sites and effects on absorption of isophane (NPH) insulin. Diabet Med 1990; 7: 795- 799.12. Saez-de Ibarra, Gallego F. Factors related to lipohypertrophy in insulin treated diabetic patients: role of educational intervention. Practical Diabetes Int 1998;15(1).

Figure 4: Injection site rotation pattern for abdomen, thighs and buttocks. Adapted from New Injection Recommendations for Patients with Diabetes, 2010 [8].

Figure 5 Two visible lipohypertrophic lesions below the umbilicus [8]

118. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J. et al. New Injection Recommendations for Patients with Diabetes.Diabetes & Metabolism 2010, 36: S3 -S18.

increases the risk of lipodystrophy and infection [4,13]. even after a single use, the risk of microbial contamination of

needle increases [14]. Distorted needle tip contributes to 31% risk of lipodystrophy

[2-4].

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Figure 6: New needle (A) and distorted needle (B) caused by reuse.

A B

2.Strauss K, Gols HD, Letondeur C, Matyjaszczyk M, Frid A. The second injection techniques event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int. 2002; 19(1): 17-21.3.Partanen TM, Rissanen A. Insulin injection practices. Pract Diabetes Int. 2000; 17(8): 252–4.4.Strauss K, Gols HD, Hannet I, Partanen TM, Frid A. A pan-european epidemiologic study of insulin injection techniques in patients with diabetes. Pract.Diabetes Int 2002; 19(3):71-6.13. Paily R. Perinephric abscess from insulin syringe reuse. Am J Med Sci 2004, 327:47–48.14. Misnikova IV, Dreval AV, Gubkina VA, Rusanova EV. The risks of repeated use of insulin pen needles in patients with diabetes mellitus. J Diabetology 2011; 1(1): 1-5.

RESEARCH AIM, OBJECTIVES, AND

HYPOTHESES

• The aim of this study is to assess patient’s knowledge of using insulin injection by studying their background and looking at the weaknesses according to the questionnaire. Then, provide the best way on how to improve their insulin injection technique.

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1. To assess the insulin injection technique in patient

with diabetes.

2. To investigate their knowledge and awareness

involving the insulin injection.

Null hypotheses1. Diabetic patients do not demonstrate proper insulin pen injection

techniques and good knowledge towards insulin injection.

Alternate hypotheses1. Diabetic patients demonstrate proper insulin pen injection techniques

and good knowledge towards insulin injection.

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METHODOLOGY

Type of study Descriptive study

Settings Outpatient Pharmacy

Department (OPD) Hospital Batu

Pahat, Johor.

Duration 1 month (December 2011)

Sample size 30

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• Subjects will be accessioned to the study based on the following inclusion and exclusion criteria:

• Subjects will be recruited using convenience sampling.

• Subjects will be required to provide verbal

consent to participate in the study.

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• The parameters evaluated [3-5,18] will be described below:

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• Total of 30 marks were given to each injection technique according to the questionnaire.

• Each step account for 1 mark.

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Marks Percentage Classification

0-7 0-24 % Poor

8-14 25-49 % Moderate

15-22 50-74 % Satisfactory

23-30 75-100 % Good

• Data were analysed with SPSS Software (ver.15) and were presented in the form of pie charts and bar charts using Microsoft Excel 2007.

• Descriptive statistics were determined.

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RESULTS AND DISCUSSION

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Part A : Demographic InformationAge Number of patients Percentage (%)

13-28 2 6.6729-44 7 23.3345-60 14 46.6761-75 7 23.33

GenderMale 17 56.67Female 13 43.33

RaceMalay 19 63.33Chinese 11 36.67Indian 0 0Others 0 0

Education LevelTertiary 2 6.67Secondary 11 36.67Primary 16 53.33None 1 3.33

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Part B : Disease Condition

Q1 : Which type of Diabetes Mellitus that you have been diagnosed?

(n=30)

2, 7%8, 27%

20, 66% Type 1 DM

Type 2 DM

Not sure

Percentage on type of DM they have been diagnosed with.

25

27%

13%

10%

50%Pain Bleeding

Bruising Nothing

Q6 : Do you find any problem with insulin injection?

(n=30)

Percentage on any problem with insulin injection.

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8, 27%

22, 73%

Compliance

Not compliance

Part C : Assessment Of Insulin Pen Injection Techniques

Q3 : How many times do you inject insulin in a day?

(n=30)

Percentage of subjects according to compliance.

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5, 17%3, 10%2, 7%

20, 66%Mixtard 30/70

Actrapid

Insulatard

Not sure

Q4 : Which type of insulin that you are using?

(n=30)

Percentage of subjects according to the type of insulin they used.

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2, 7%

8, 27%

16, 53%

4, 13%

Once only

Twice

Thrice

Until pain is felt

Q9 : How many times does the same needle is used?

(n=30)

Percentage and number of subjects according to the needle usage.

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Part C(ii) : Steps of Insulin Pen InjectionClassificati

on & Marks

f

Poor(0-7) 0

Moderate(8-14) 5

Satisfactory(15-22) 22Good

(23-30) 3

CONCLUSION

• The majority of the patients using insulin in OPD in Hospital Batu Pahat does not have a good insulin injection technique and 90 % of the patients needed to be re-educated by the pharmacists.

• They show lack of knowledge towards insulin pen injection because most of them preferred to answer `Not sure` for most of the questions that had been asked.

• Recounsel the patients and giving pamphlet can be done to improve the knowledge and techniques of patients taking insulin as a choice of therapy.

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• A more appropriate research can be done in the future to assess back patients knowledge after those initiatives had been done.

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REFERENCES

1. Letchuman GR, Nazaimoon WMW, Mohamad WBW, Chandran LR, Tee GH, Jamaiyah H, Isa MR, Zanariah H, Fatanah I, Ahmad Faudzi YA. Prevalence of diabetes in the Malaysian National Health Morbidity Suevey III 2006. Med J Malaysia 2010; 65(3): 173-9.

2. Ministry of Health Malaysia, Persatuan Diabetes Malaysia (PDM) and Academy of Medicine. Clinical Practice Guidelines: Management of type 2 diabetes mellitus, 4th ed. 2009.

3. Strauss K, Gols HD, Letondeur C, Matyjaszczyk M, Frid A. The second injection techniques event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int. 2002; 19(1): 17-21.

4. Partanen TM, Rissanen A. Insulin injection practices. Pract Diabetes Int. 2000; 17(8): 252–4.5. Strauss K, Gols HD, Hannet I, Partanen TM, Frid A. A pan-european epidemiologic study of insulin injection techniques in patients with

diabetes. Pract.Diabetes Int 2002; 19(3):71-6.6. Dunning T et al. Insulin delivery devices. Australian Prescriber 2002;25:136-138.7. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J. et al. New Injection Recommendations for Patients with Diabetes. Diabetes &

Metabolism 2010, 36: S3 -S18.8. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, Letondeur C, Sauvanet JP, Tubiana-Rufi N, Straus K. The Third Injection

Techniques Workshops in Athens (TITAN). Diabetes and Metabolism 2010;36:19-29.9. Young RJ, Hannan WJ, Frier BM, Steel JM, Duncan Leslie JP. Diabetic lipohypertrophy delays insulin absorption. Diabetes Care 1984; 7

(5).10. Thow JC, Johnson AB, Marsden S, Taylor R, Home PD. Morphology of palpably abnormal injection sites and effects on absorption of

isophane (NPH) insulin. Diabet Med 1990; 7: 795-799.11. Franzén I, Ludvigsson J. Specific instructions gave reduction of lipomas and improved metabolic control in diabetic children. July 1997

IDF, Helsinki (abstract).12. Saez-de Ibarra, Gallego F. Factors related to lipohypertrophy in insulin treated diabetic patients: role of educational intervention.

Practical Diabetes Int 1998;15(1).13. Jehle PM, Micheler C, Jehle DR, Breitig D, Boehm BO. Inadequate suspension of neutral protamine Hagedorn (NPH) insulin in pens.

Lancet 1999; 354 (9190):1604–1607.14. Jehle PM. Pens: Richtige Mischung = weniger Unterzuckerungen. Diabetes J 2000; 5: 46–50.15. Paily R. Perinephric abscess from insulin syringe reuse. Am J Med Sci 2004, 327:47–48.16. Misnikova IV, Dreval AV, Gubkina VA, Rusanova EV. The risks of repeated use of insulin pen needles in patients with diabetes mellitus. J

Diabetology 2011; 1(1): 1-5.17. Danish Nurses Organization. Evidence based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus, 2 nd ed,

December 2006. 18. Carina DC, Anders F, Ruth G, et al. Results and analysis of the 2008-2009 Insulin Injection Technique Questionnaire survey. Journal of

Diabetes 2 (2010) 168-179.

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