COMMENTARY

Tips for Demystifying Injections in Diabetes

Anne L. Peters, MD

Disclosures

October 12, 2017

Today I'm going to teach you how to teach a patient to give an injection. I want to make it clear that this does not need to be stressful for either you or the patient. I hear over and over again how injectable therapy is a barrier, but I do not think from a physician's perspective that this should be a barrier at all.

We should all be expert educators. I teach my patients how to give insulin and glucagon-like peptide 1 receptor agonists (GLP-1 RAs). I'll show you the way I do it.

The Basics

You must be prepared. Always make sure that you are sitting down and have something nearby to collect trash; a sharps container is a good idea. I make sure that I have a little table next to me like the exam table, or sometimes I just use my lap.

I'm going to demonstrate how to give liraglutide by injecting it into something that is not the patient. I bring in an orange, but you can also use fake skin products. I bring in pen needles. I make sure I'm ready, then I sit down in front of the patient.

It's good to be a little klutzy so that patients understand that you do not have to be perfect at this.

I open the box that includes the pen and sometimes needles. I take out the package insert and show it to the patient so that they can take it home and review what I've taught them.

While I take out the pen, I tell the patient these rules: Any injectable that they are not using should be stored in the refrigerator, and the injectable they are using can be kept out at room temperature. I show them that the pen consists of the part that contains the insulin—or in this case, liraglutide—and the pen cap. I take off the pen cap and show them the top. I show them a pen needle and how to screw it on.

It's that simple. This little piece goes into the trash. Remember, having somewhere to place trash is very important.

I explain that the needle has two parts: They should save this opaque outer part and pull off this little inner part and put it in the trash. You can see the tiny needle. I show them the dial of whatever it is that I'm giving. With the liraglutide pen, you flush it the first time you use it but not thereafter.

I show them how to dial up the dose, and then I show them that you push the end. I show them that whatever the drug is, in this case liraglutide, it comes through the end.

I show them whatever their first dose is going to be. Here, it's going to be 0.6 mg. Then I show them how to hold the pen. I do not know if this is the only way, but I show them to grab it with their fingers and keep their thumb on the top. I show them how to give it to an orange.

Boom, push, hold for a couple of seconds, and pull out. Done. I show them how to recap the needle, take it off, and stick it in the trash. I take the pen, put the cap back on, and tell them to put it down wherever they will use it the next day.

I do this process once with an orange or some fake skin, and then I have them do it. If the patient is actually going to need it that day, I have them do the first injection right there. If they are going to give it at home, I'll just have them push the needle in under the skin, but not actually inject whatever it is that they are going to be giving.

This is easy because I know the steps and do not make it complicated. I tell almost everybody to inject in their abdomen. I have them give it to themselves in their abdomen and tell them to avoid the area around the umbilicus, which I show them with my fingers.

That is an easy site for most of my overweight patients with type 2 diabetes. With some of the leaner, younger individuals, you might have to discuss site rotation. I talk about using a different place every day, and I show them the handout that shows additional sites.

It's easiest if I'm just very simple. I show them how to do it, then I have them do it once or at least practice once. By then, the patient feels very comfortable and is able to go home and give the injection.

Also, many companies now have very clear tutorials online that a patient can watch.

Discussing Hypoglycemia

The reason I showed you liraglutide first is that you do not have to talk about hypoglycemia. When you give somebody a drug that can cause hypoglycemia, such as any form of insulin, or if you are adding a GLP-1 receptor agonist (RA) to a patient on a sulfonylurea agent, you need to talk about hypoglycemia.

There are two key points. A patient with type 2 diabetes who has never had insulin and who is not usually low is going to be really symptomatic if they develop hypoglycemia. I tell them what it feels like to go low. I also tell them that in most cases, it's not going to be a serious issue because they will be able to eat and treat it quite quickly.

I stress that it's important to let me know if they are having recurrent episodes of hypoglycemia or even one or two episodes in the beginning so that I can adjust their medication doses. I've created a handout—you can create your own—that talks about signs and symptoms of hypoglycemia and how to treat it. Remember, always make sure that you discuss hypoglycemia and give that information to the patient when you are going to have the patient go home and inject some insulin or a GLP-1 RA along with a sulfonylurea agent.

Now I'm going to demonstrate giving insulin, because people are often more afraid of insulin, in part because of hypoglycemia. I take out the package literature and give it to the patient. I take out the pen; this happens to be Basaglar®, which is follow-on glargine. I show them the tip and how to put the needle on. I put everything in the trash so that I'm always neat and tidy.

I take the top off. In the case of insulin, you are just going to dial it up. You are always going to tell them to prime it every time.

The last thing I want is a confused patient.

I show them how it goes out like that. I then do a new dose. I'm giving this "person" 20 units because you can see how the plunger comes out. I have them give it to an orange. Hold it just the right way. Give the insulin. It's really easy.

I showed you that when I dialed this up, this plunger comes out. I know this is a subtle point, but it is important, because with the Novo Nordisk FlexTouch pens®, the plunger does not come out when you dial up the dose. I'm not saying that this is better or worse; I'm just saying it's different. Sometimes patients get confused. The last thing I want is a confused patient.

When you use this pen and dial up the dose, this plunger end does not come out; it stays flushed. The patient will give the dose. They will have to hold their thumb in until the dose is fully given. They can see by the little markings going down on the side that they know they have given it.

This end does not come up the way this end does. It's just a different pen mechanism. But because they are both on the market, I want to make sure that you tell your patients which one they are going to be using so that they are not surprised when they do not see the end of the pen coming up.

Just Another Way to Give Medicine

That's how I do it. Again, I'm prepared. I'm quick. I do it myself and then I have the patient do it. I give them information to take home. I give them a clear plan for follow-up. Most patients are more than willing to do it, especially when they see the tiny size of the pen needle.

When I have them give the first injection into the abdomen, I make sure that they are aware of any potential side effects, including hypoglycemia if it's insulin or a GLP-1 RA in a patient on a sulfonylurea agent. Patients generally do really well.

In general, our patients want to reach their targets and they want to feel better. As we have more and more injectable agents and combination GLP-1 RA and insulin therapy injectables, we need to be clear and comfortable in teaching our patients. An injection is just another way to give a medicine. Frankly, it's the way we give peptide hormones. It's a way that patients can have healthier blood sugar levels and reach their targets.

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