Many patients using injectable insulin experience poor results due to improper injection methods and insufficient education. To tackle this issue, the FITTER Forward initiative created some best practices designed to enhance insulin administration. Created by 16 diabetes experts from around the world, the guidelines emphasize correct injection procedures, prevention of injection-related complications, and patient-focused guidance. The overall aim is to improve diabetes outcomes by equipping healthcare providers, patients, and caregivers with clear, actionable strategies for better insulin injection treatment outcomes.

Below are some of the key components of the guidelines, summarized for your convenience. 

Section 1 — Understand How Characteristics of Physiology, Devices, and Injection Technique Impact Injection Experiences
  • Needle length should be adequate to reliably administer insulin to the subcutaneous adipose tissue.
  • Thin and sharp needles with increased flow rate reduce injection pain.
  • Pen base design can influence the impact of excess force.
Section 2 — Evidence-Based Injection Technique Procedure

Insulin Storage and Handling Recommendations:

  • Unopened insulin vials/pens should be stored in a refrigerator at 2 to 8 °C (36 to 46 ℉), without freezing or food contamination.
  • Patients should be advised to check the temperature consistency in their home refrigerator.
  • Insulated bags or cooler packs should be used if insulin is brought outside in hot or cold temperatures.
  • Once opened, insulin vials/pens should be stored at ambient temperatures (15 to 30 °C or 59 to 86 ℉) away from direct sunlight exposure until the expiration date designated by the manufacturer (often 28 days).
  • Removing insulin from a prefilled disposable insulin pen using a syringe to fill another device should be avoided when possible.
  • Avoid shaking insulin when inspecting that it is not cloudy or expired.
  • Let refrigerated insulin reach room temperature before injection to limit pain and complications.

Selection, Preparation, and Rotation of Injection Site Recommendations:

  • Recommended injection sites include the abdomen, thighs, buttocks, and upper arms.
  • Disinfect injection site with alcohol swap and allow to air dry.
  • Avoid injecting through clothing, into scars, stretch marks, tattoos, or into skin areas that exhibit edema, infection, inflammation, or ulceration.
  • Sites of injection should be rotated to avoid skin thickening and lipodystrophy.
  • HCPs should review injection recommendations annually with patients.

Proper Injection Technique for Pens:

  • HCPs should educate patients on how to use the selected device and perform a follow-up assessment to gauge their understanding.
  • Patients should observe at least one drop of insulin at the tip of the needle to confirm the injection is primed.
  • For the majority of adults using a 4-mm needle, the pen should be held at a 90° angle to the skin surface for injection, regardless of whether a skin lift is performed. A 5-mm needle length may also be used if a 4-mm needle is not available or if a 5-mm needle is preferred.
  • Inject insulin slowly, apply even pressure to the device’s button, then wait approximately 10 seconds before removing the needle to avoid insulin leakage.

Proper Injection Technique for Syringes:

  • Syringe needle use in patients with BMI <19 kg/m² or those less than 6 years of age is not recommended since the risk of IM injections remains high even with a correctly raised skin lift.
  • The appropriate syringe needle length for most adults and adolescents with diabetes is 6 mm if it is used, which requires a skin lift with 90° injection angle for patients with a BMI of 19 to 25 kg/m² to prevent IM injection.
  • HCPs should verify syringes have the appropriate markings for the prescribed concentrations.
  • Patients should be instructed on how to draw insulin from a vial without creating a vacuum, and how to check for (and remove) air bubbles in the drawn insulin.

Postinjection Best Practices:

  • Patients should avoid reusing needles.
  • HCPs should educate patients on the risks of needle reuse.
  • Needles should never be shared or reused between patients.
  • Clearly label all insulin pens/cartridges/vials.
  • Dispose of needles safely in a certified waste receptacle.
  • Patients should adhere to local health guidelines regarding needle disposal when traveling. 
Section 3 — Implement Proactive Risk Reduction and Detection of Lipodystrophy
  • HCPs should explain the risks of lipodystrophy and lipohypertrophy to patients.
  • Lipohypertrophy assessment should be routine practice. Ultrasound detection is recommended when available.
Section 4 — Utilize Structured Injection Technique Training for Optimal Outcomes
  • HCPs should strive to deliver personalized insulin delivery education for each patient based on clinical, emotional, and social needs.
  • Addressing patient concerns early can reduce patient anxiety and lead to better injection outcomes.
  • Frequently assess and update insulin delivery practices, educational tactics, and technology. 
  • Patients should be instructed to report unusual pain, unusual lack of pain, leaking, bleeding, bruising, and needing to increase the force of injection.
  • Review injection sites in person, rather than through telehealth, when possible.

View the full Advance Insulin Injection Technique and Education with FITTER Forward Expert Recommendations guidelines for a complete look at the recommendations.

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