MON-703 Injection Technique over Insulin Dose - Nuances in Diabetes Therapy

Introduction Optimal insulin injection technique is crucial for therapeutic success in patients with diabetes who require insulin therapy for glycemic control. One of the causes for failure to reach glycemic goals can be attributed to improper injection technique. Problems related to poor injection technique may arise at a later stage and hence, may lead to a major barrier to intended glycemic control. We present a patient with worsening glycemic control and significant insulin requirement due to ineffective injection technique. Our case highlights the importance of direct observation of the patient injecting insulin, even for those who have been on insulin therapy for years. Case Presentation A 55-year-old woman with T2DM and Class III obesity was referred for endocrine consultation with HbA1c >12% for 9 months despite adhering to 4.7 unit/kg/day basal bolus daily Insulin, Metformin 1000 mg twice daily and liraglutide 1.8 mg daily. Secondary causes of insulin resistance were ruled out. Initial review of injection technique on an insulin-injection pad failed to identify the error. However, a leakage was observed when patient was asked to demonstrate injection technique on herself, using the BD AutoShield Duo needle, which she was using at that time. Patient was advised to switch to BD nano needles and given proper training. Following this adjustment, her HbA1c improved to 6.9% within 3 months with a decrease in daily insulin requirement to 1 unit/kg/day. Discussion In optimizing glycemic control, proper insulin injection technique is as essential as the appropriate type and dose of insulin; however, this is often overlooked. Studies assessing proper insulin injection technique by direct observation are limited. Problems experienced by patients are rarely brought up and often neglected during the follow-up visits. Supervision of injection technique periodically can help identify injection errors. The BD AutoShield Duo offers the distinct advantages of concealing the needle which benefits those who have an aversion to needles and reduces the risks of accidental needlesticks. The force required to deliver a successful injection of insulin using this needle is greater in comparison to traditional needles. Such force and lack of direct visualization may potentially lead to failure of insulin delivery. Such challenges may be more obvious in patients with obesity. Our case highlights the importance of periodic review of insulin injection technique, particularly when glycemic control is suboptimal, and emphasizes the correct choice of insulin pen needle. References 1.King, Laila. “Subcutaneous insulin injection technique.” Nursing Standard, vol. 17, no. 34, 2003, p. 45+. Academic OneFile, https://link.galegroup.com/apps/doc/A130629162/AONE?u=googlescholar&sid=AONE&xid=5f28fd49. Accessed 18 Nov. 2018.