16 Apr Diabetes: Insulin Injection Techniques and Education Updated with FITTER Forward Recommendations

MedicalResearch.com with:

Dr. Klonoff

Dr. David Klonoff MD
Medical Director of the Dorothy L. and James E. Frank Diabetes Research Institute of
Mills-Peninsula Medical Center
Clinical Professor of Medicine at UCSF

MedicalResearch.com: What is the background for this the FITTER Forward expert recommendations?

• The focus of healthcare professionals (HCPs) tends to be primarily on the drug and overall treatment, while the administration of insulin and other peptide medications—which can play a critical role in outcomes—is often overlooked. The Fitter Forward group, consisting of 16 diabetes experts from 13 countries, decided to update a previous set of recommendations that was almost a decade old, with newly published evidence and materials. This new report, published in the April 2025 edition of Mayo Clinic Proceedings, highlights recent advances in needle technology, the physiology of insulin injections, and proper injection techniques.

MedicalResearch.com: Have the delivery devices for insulin or other medications changed since the last recommendation statement?

• Since the last set of recommendations, the data now clearly supports a 4mm, 32G, non-posted contoured needle base as the best type of needle for all adults and children with diabetes.  This length and needle geometry provides the best combination of features to minimize 1) injection into the muscle (which is associated with unpredictable absorption and hypoglycemia) as well as 2) injection pain and 3) a great amount of force necessary for drug delivery.  The figure below illustrates how a 4 mm needle will not reach muscle but an 8 mm needle can sometimes reach muscle.

MedicalResearch.com: Do the delivery devices used for different medications require different techniques?

• The optimal injection technique depends on the injection route (such as intramuscular, subcutaneous, or intradermal).  FITTER Forward focuses on the subcutaneous injection of insulin and other peptides, like GLP-1 receptor agonists. Insulin delivery devices are commonly administered subcutaneously using either a pen with a pen needle or a vial with a syringe and a needle.

 MedicalResearch.com:What are the main FITTER Forward recommendations?

• Six key recommendations include:
• 1) Needle Length: 4 mm pen needles are suitable for all adults and children with diabetes.  5 mm needles can be used as an alternative if 4 mm needles are unavailable. 3.5-mm pen needles have initial evidence that they are noninferior to 4-mm pen needles, although the currently available 3.5-mm pen needles have a high gauge number (34G), contributing to reports of increased manual effort during injection. Longer needles (6-8 mm) are discouraged due to the higher risk of intramuscular (IM) injection.
• 2) Pen Base Design: A non-posted, contoured base distributes pressure more widely, reducing overall force and risk of bruising. A Posted base may increase risk of bruising and IM injection due to focused pressure.
• 3) Needle Gauge: Current evidence suggests that 32G reduces pain without being too fragile.
• 4) Skin Lift Technique: Necessary for individuals with low BMI, older adults, pregnant women, and children to ensure insulin is delivered to the subcutaneous (SC) tissue.
• 5) Insulin injection sites: the abdomen, thighs, buttocks, and upper arms, are areas that have sufficient SC fat to minimize the risk of IM injection. The arm is the least preferred site for self-injection due to the difficulty in achieving the optimal 90° angle and performing a skin lift independently.
• 6) Lipohypertrophy: Lipohypertrophy (which is a hard area of fibrosis and inflammation caused by repeated excessive and incorrect insulin injections into the same spot) should be routinely sought after in people with diabetes injecting insulin. Ultrasound is a superior detection method, recommended where available; otherwise, structured palpation and visual examination should be used. Once detected, it is recommended that patients avoid injecting into affected sites and reduce risk through systematic site rotation, avoiding cold insulin, and not reusing needles. For more information you can view the publication here.

MedicalResearch.com: Can these recommendations be disseminated or taught through telemedicine or YouTube?

• The FITTER Forward initiative was designed to provide a user-friendly approach to improving insulin injection techniques. It offers many digital resources, including a website, videos, supporting imagery, and infographics, making the information accessible and engaging via telehealth portals for both healthcare professionals and people living with diabetes. These recommendations can be leveraged through video communications such as telemedicine or YouTube.  The increasing use of telemedicine poses challenges for assessing lipohypertrophy, These skin changes can appear as unsightly lumps if they are superficial, but if they are deep, then they can be difficult to identify virtually. However, valuable information can still be gathered through visual assessment and self-reporting by people with diabetes.

MedicalResearch.com: Is there anything else you would like to add? Any disclosures?

• Proper insulin injection techniques will minimize the glycemic variability, frequent hypoglycemic episodes, and development of unsightly lipohypertrophy that are common with improper injection techniques.  This is why the FITTER Forward report can be helpful for clinicians who manage individuals who use insulin.
• You can visit https://fitterdiabetes.com/ for additional information and resources. The FITTER Forward global expert advisory board members, including me, received funding from embecta for participating.  However, the group’s recommendations were developed by us independently from embecta, which is in keeping with the company’s policies for peer-reviewed publications.

Citation:

—————–

The information on MedicalResearch.com is provided for educational purposes only, and is in no way intended to diagnose, cure, or treat any medical or other condition.
Some links may be sponsored. Products are not warranted or endorsed.
Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.

Last Updated on April 16, 2025 by Marie Benz MD FAAD