Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.

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Background:  The efficacy of injection therapy in diabetes depends on correct injection technique and, to provide patients with guidance in this area, we must understand how they currently inject. Methods:  From September 2008 to June 2009, 4352 insulin‐injecting Type 1 and Type 2 diabetic patients from 171 centers in 16 countries were surveyed regarding their injection practices. Results:  Overall, 3.6% of patients use the 12.7‐mm needle, 1.8% use the 12‐mm needle, 1.6% use the 10‐mm needle, 48.6% use the 8‐mm needle, 15.8% use the 6‐mm needle, and 21.6% use the 5‐mm needle; 7% of patients do not know what length of needle they use. Twenty‐one percent of patients admitted injecting into the same site for an entire day, or even a few days, a practice associated with lipohypertrophy. Approximately 50% of patients have or have had symptoms suggestive of lipohypertrophy. Abdominal lipohypertrophy seems to be more frequent in those using the two smaller injection size areas, and less frequent in those using larger areas. Nearly 3% of patients reported always injecting into lipohypertrophic lesions and 26% inject into them sometimes. Of the 65% of patients using cloudy insulins (e.g. NPH), 35% do not remix it before use. Conclusions:  It is clear from the latest survey that we have improved in certain areas, but that, in others, we have either not moved at all or our efforts have not yielded the results we expected. The results of the present survey are available online on a country‐by‐country and question‐by‐question basis at http://www.titan-workshop.org.

Objective: This study determined the influence of needle length for insulin administration on metabolic control and patient preference in obese patients with diabetes mellitus. Methods: In this multicenter, open-label crossover study, insulin pen needles of two different lengths (5 mm and 8 mm) were compared. A total of 130 insulin-treated type 1 and type 2 diabetes patients with a body mass index !30 kg/m 2 were randomized, and 126 patients completed the study. Patients started using the 5-mm needle for 3 months, after which they switched to injecting insulin with the 8-mm needle for another 3 months, or vice versa. Hemoglobin A1c (A1C), fructosamine, and 1,5-anhydroglucitol were measured, and self-reported side effects and patient preference were recorded. Results: No within-group changes were observed with respect to A1C, serum fructosamine, 1,5-anhydroglucitol, hypoglycemic events, bruising, and pain. When data of all 126 subjects were pooled, there was a small, but significant, difference between needle lengths (5-mm, A1C 7.47 AE 0.9%; 8-mm, 7.59 AE 1.0%; P ¼ 0.02). Patients reported less bleeding with the 5-mm needle (P ¼ 0.04) and less insulin leakage from the skin with the 8-mm needle (P ¼ 0.01). There were no significant differences in patient preference, with 46% of the patients preferring the 5-mm needle, 41% the 8-mm needle, and 13% not preferring a particular needle length. Conclusions: A 5-mm needle is similar to an 8-mm needle in obese patients with diabetes with respect to metabolic control, injection-related complaints, or patient preference and can be used safely.