Recomendaciones sobre técnicas de inyección y titulación de insulinas para personas con diabetes

Autores/as

  • Víctor Commendatore Hospital San Martín de Paraná, Paraná, Entre Ríos, Argentina
  • Cristina Faingold Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
  • Gustavo Frechtel Hospital de Clínicas (UBA), Ciudad Autónoma de Buenos Aires, Argentina
  • Graciela Fuente Hospital C. Durand, Ciudad Autónoma de Buenos Aires, Argentina
  • María Amelia Linari Unión Obrera Metalúrgica (UOM), Vicente López, Provincia de Buenos Aires, Argentina
  • Carla Musso Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
  • Miriam Tonietti Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina

DOI:

https://doi.org/10.47196/diab.v49i1.194

Palabras clave:

diabetes mellitus, insulina, titulación, glucagón, análogos de glp1

Resumen

Introducción: dada la existencia de limitaciones importantes que pueden influir en la técnica de inyección y por consiguiente en la evolución sobre el tratamiento de la diabetes mellitus se realizaron estas recomendaciones, las cuales fueron adaptadas culturalmente a nuestro país.

Materiales y métodos: se realizó una revisión bibliográfica vinculada a las técnicas de inyección de insulina, las formas de titulación de la misma y el uso de otros fármacos inyectables como
el glucagón y los análogos de GLP1. Se estudiaron las barreras terapéuticas en el tratamiento con insulina y el rol que ocupa la educación sobre este tema dentro del equipo de salud tratante.

Conclusiones: existe una amplia oferta de insulinas y sus análogos. Es responsabilidad del equipo de salud conocer las características de las mismas y realizar las indicaciones más adecuadas para conseguir las metas glucémicas propuestas para cada paciente en particular, disminuir el riesgo de las complicaciones asociadas a la enfermedad y contribuir a la mejor calidad de vida
posible para todas las personas con DM.

Biografía del autor/a

Víctor Commendatore, Hospital San Martín de Paraná, Paraná, Entre Ríos, Argentina

Jefe del Servicio de Endocrinología, Diabetes y Nutrición

Cristina Faingold, Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina

Responsable Médico del Servicio de Endocrinología de la Unidad Asistencial Dr. César Milstein; Médica de Planta del Instituto Cardiovascular de Buenos Aires; Directora de la Carrera de Médico Especialista en Endocrinología

Gustavo Frechtel, Hospital de Clínicas (UBA), Ciudad Autónoma de Buenos Aires, Argentina

Médico Especialista en Nutrición, Doctorado en la Universidad de Buenos Aires (UBA); Profesor Titular de la Cátedra de Nutrición, Departamento de Medicina (UBA); Jefe de la División Nutrición del Hospital de Clínicas (UBA)

Graciela Fuente, Hospital C. Durand, Ciudad Autónoma de Buenos Aires, Argentina

Especialista en Diabetes y Nutrición; Jefa de la Unidad de Nutrición

María Amelia Linari, Unión Obrera Metalúrgica (UOM), Vicente López, Provincia de Buenos Aires, Argentina

Coordinación de la Sección Endocrinología y Nutrición

Carla Musso, Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina

Servicio de Endocrinología y Diabetes de la Unidad Asistencial Dr. César Milstein

Miriam Tonietti, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina

Médica Pediatra; Médica especialista en Nutrición; Médica de planta del Servicio de Nutrición del Hospital de Niños Ricardo Gutiérrez

Citas

Mitchell VD, Porter K, Beatty SJ. Administration technique and storage of disposable insulin pens reported by patients with diabetes. The Diabetes Educator 2012 38: 651 originally published online. Citado: 20 June 2012. http://tde.sagepub.com/content/38/5/651.

Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, Letondeur C, Sauvanet J-P, Tubiana-Rufi N, Strauss K. The First UK Injection Technique Recommendations 2º Edition. Octubre 2011; p: 9-14.

Frida A, Hirschb L, Gasparc R, Hicksd D, Kreugele G, Lierschf J, Letondeurg C, Sauvaneth JP, Tubiana-Rufii N, Straussj K. New injection recommendations for patients with diabetes. Diabetes & Metabolism. 201; 36.p: S3-S18.

Scottish Intercollegiate Guidelines Network. SIGN 50. First publication: 2008. Review: november 2011. www.sign.ac.uk/guidelines/fulltext/50/.

Federación Española de Asociaciones de Educadores en Diabetes. Guía práctica para educadores en diabetes. Inyección de insulina, 2007. http://www.guiasalud.es/egpc/diabetes.

Menéndez SA, García Soidán J, Navarro Pérez J, Goday Arno A, Gorgojo Martínez JJ, et al. Consenso del Grupo de Estudio de la Diabetes en Atención Primaria en el inicio de insulinización de pacientes con diabetes mellitus tipo 2. REDGEDAPS 2009; p: 11-13. http://www.redgdps.org/pdf.

Glasgow Diabetes Managed Clinical Network. Guidelines for insulin adjustment in Primary Care. Reviewed January 2010.

BD cuidados para la diabetes. Jeringas para insulina. Disponible en: http://www.bd.com/mx/diabetes/main.aspx?cat=3258&id=3323.

Coscelli C, Lostiab S, Lunettac M, et al. Safety, efficacy, acceptability of a pre-filled insulin pen in diabetic patients over 60 years old. Diabetes Res. Clin. Pract. 1995; 28: 173-177. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/8529495.

Danne T, Forst T, Deinhard J, et al. No effect of insulin pen with memory function on glycemic control in a patient cohort with poorly controlled type 1 diabetes: a randomized open-label study. J. Diabetes Sci. Technol. 2012; 6: 1392-97. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/23294785.

Zahn JD. Analysis: desirable attributes of insulin injection pens that drive patient preference and compliance. J. Diabetes Sci. Technol. 2011 Sep 1; 5 (5): 1210-1. Disponible en: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208883/pdf/dst-05-1210.pdf.

Pafili K, Papanas N. The importance of patient compliance with insulin pens: how can a new userfriendly pen help? Expert Opin. Drug Deliv. 2014 May 11 (5): 629-32. Disponible en: http://informahealthcare.com/doi/pdf/10.1517/17425247.2014.894505.

Hemmingsen H, Niemeyer M, Rye Hansen M, et al. A prefilled insulin pen with a novel injection mechanism and a lower injection force than other prefilled insulin pens. Diabetes Technology & Therapeutics, Vol. 13, Nº 12, 2011. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/?term=Hemmingsen+H+2011.

Pafili K, Papanas N. The importance of patient compliance with insulin pens: how can a new user-friendly pen help? Expert Opin. Drug Deliv. 2014 May; 11 (5): 629-32. Disponible en: http://informahealthcare.com/doi/pdf

Liebert MA, Krzywon M. Study on the dosing accuracy of commonly used disposable insulin pens. Diabetes Technology & Therapeutics, Vol. 14, Nº 9, 2012. Disponible en: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429299/pdf/dia.2011.0298.pdf.

Aronson R, Gibney M, Oza K, et al. Insulin pen needles: effects of extra-thin wall needle technology on preference, confidence, and other patient ratings. Clin. Ther. 2013 Jul; 35 (7): 923-933. Disponible en: http://ac.els-cdn.com/S0149291813003081/1-s2.0-S0149291813003081-main.pdf?_tid=6f6637a0-1061-11e4-ac4b-00000aacb362&acdnat=1405897319_20f4f10e1d2560e2a83d9782f6aec0e9.

Hirsch L, Gibney M, Berube J, et al. Impact of a modified needle tip geometry on penetration force as well as acceptability, preference and perceived pain in subjects with diabetes. J. Diabetes Sci. Technol. 2012 Mar 1; 6 (2): 328-35. Disponible en: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3380774/pdf/dst-06-0328.pdf.

Kiss P, De Meester M, Braeckman L. Needlestick injuries in nursing homes: the prominent role of insulin pens. Control Hosp. Epidemiol. 2008 Dec; 29 (12): 1192-4. Disponible en: http://www.jstor.org/stable/pdfplus/10.1086/592407.pdf?acceptTC=true&jpdConfirm=true.

Davis E, Bebee A, Crawford LA, Destache CH. Nurse satisfaction using insulin pens in hospitalized patients. The Diabetes Educator, 2009, 35: 799. Dispoible en: http://tde.sagepub.com/content/35/5/799.full.pdf+html.

Zhou M, Wang Y, Dong Y, Sun Q, Li Y. A comparative study of the effects of needle free (INJEX30) versus insulin pen injection on insulin absorption in diabetic patients. Zhonghua Nei Ke Za Zhi. 2013 Sep; 52 (9): 741-4. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/24314163.

Elsemiek E, Cees J, Bastiaan E. Needle-free jet injection of rapid-acting insulin improves early postprandial glucose control in patients with diabetes. Diabetes Care. November 2013, Vol. 36, Nº 11 3436-3441. Disponible en: http://care.diabetesjournals.org/content/36/11/3436.abstract?sid=2ffac018-d309-4b49-9699-4ab8ecd3adc0.

Costa Gil J, Ferraro M, Ruiz ML, y col. Guía para el uso de bombas de insulina en Argentina. Disponible en: http://www.diabetes.org.ar/docs/2012_guia_bombas_insulina.pdf.

Sociedad Argentina de Diabetes. Comité de bombas de insulina. Tratamiento con infusión continua de insulina subcutánea http://www.diabetes.org.ar/docs/recomendaciones.pdf.

King L. Subcutaneous insulin injection technique. Nurs Stand 2003; 17:45-52.

Jehle PM, Micheler C, Jehle DR, Breitig D, Boehm BO. Inadequate suspension of neutral protamine hagendorn (NPH) insulin in pens. Lancet 1999; 354: 1604-7.

Brown A, Steel JM, Duncan C, Duncun A, Mc Bain AM. An assessment of the adequacy of suspension of insulin in pen injectors. Diabet Med 2004; 21:604-608.

Nath C. Mixing insulin: shake, rattle or roll? Nursing 2002; 32:10.

Springs MH. Shake, rattle, or roll? Challenging traditional insulin injection practices Am. J. Nurs. 1999; 99:14.

Bohannon NJ. Insulin delivery using pen devices. Simple-to-use tools may help young and old alike. Postgrad Med. 1999; 106:57-8.

Dejgaard A, Murmann C. Air bubbles in insulin pens. Lancet 1989; 334: 871.

Ahern J, Mazur ML. Site rotation. Diabetes Forecast 2001;54:66-68.

Perriello G, Torlone E, Di Santo S, Fanelli C, De Feo P, Santusanio F, Brunetti P, Bolli GB. Effect of storage temperature on pharmacokinetics and pharmadynamics of injectable therapy mixtures injected subcutaneously in subjects with type 1 (injectable therapy-dependent) diabetes mellitus. Diabetologia 1988; 31:811-815.

Ginsberg BH, Parkes JL, Sparacino C. The kinetics of injectable therapy administration by injectable therapy pen devices. Horm. Metab. Research. 1994; 26:584-587.

Seidenari S, Giusti G, Bertoni L, Magnoni C, Pellacani G. Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound. Dermatology 2000; 201:218-22.

Frid A. Fat thickness and insulin administration, what do we know? Infusystems Int. 2006; 5: 17-9.

Tafeit E, Möller R, Jurimae T, Sudi K, Wallner SJ. Subcutaneous adipose tissue topography (SAT-Top) development in children and young adults. Coll. Antropol. 2007; 31:395-402.

Yakushiji F, Fujita H, Terayama Y, et al. The best insulin injection pen device for caregivers: results of injection trials using five insulin injection devices. Diabetes Technol. Ther. 2010; 12:143-148.

Williams AS, Schnarrenberger PA. A comparison of dosing accuracy: visually impaired and sighted people using insulin pens. J. Diabetes Sci. Technol. 2010; 4:514-521.

Masuda K, Aoki K, Kikuchi K, et al. Self-injection of insulin using appropriate support devices in handicapped subjects with diabetes. Diabetes Technol. Ther. 2010; 12:483-490.

Engström L, Jinnerot H, Jonasson E. Thickness of subcutaneous fat tissue where pregnant diabetics inject their insulin. An ultrasound study. IDF Meeting Mexico City, 2000.

Fleming DR, Jacober SJ, Vandenberg MA, Fitzgerald JT, Grunberger G. The safety of injecting insulin through clothing. Diabetes Care. 1997; 20:244-247.

Joy SV. Clinical pearls and strategies to optimize patient outcomes. Diabetes Educ. 2008; 34:54S-59S.

Seyoum B, Abdulkadir J. Systematic inspection of injectable therapy injection sites for local complications related to incorrect injection technique. Trop Doct. 1996; 26:159-161.

Seyoum B, Abdulkadir J. Systematic inspection of insulin injection sites for local complications related to incorrect injection technique. Trop Doct 1996; 26:159-61.

Johansson UB. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care 2005; 28:2025-7.

Overland J, Molyneaux L, Tewari S, Fatouros R, Melville P, Foote D, et al. Lipohypertrophy: Does it matter in daily life? A study using a continuous glucose monitoring system. Diabetes Obes. Metab. 2009; 11:460-3.

Teft G. Lipohypertrophy: patient awareness and implications for practice. J. Diab. Nursing 2002; 6:20-3

Hambridge K. The management of lipohypertrophy in diabetes care. Br. J. Nurs. 2007; 16:520-4.

Jansá M, Colungo C, Vidal M. Actualización sobre técnicas y sistemas de administración de la insulina (II). [Update on insulin administration techniques and devices (II)]. Av. Diabetol. 2008; 24:255-69.

De Villiers FP. Lipohypertrophy a complication of insulin injections. S. Afr. Med. J. 2005; 95: 858-9.

Hauner H, Stockamp B, Haastert B. Prevalence of lipohypertrophy in insulin-treated diabetic patients and predisposing factors. Exp. Clin. Endocrinol. Diabetes 1996; 104:106-10.

Kreugel G, Beter HJM, Kerstens MN, Maaten ter JC, Sluiter WJ, Boot BS. Influence of needle size on metabolic control and patient acceptance. Europ. Diab. Nursing 2007; 4:51-5.

Byetta Pen User Manual. Eli Lilly and Company, 2007.

Calara F, Taylor K, Han J, Zabala E, Carr EM, Wintle M, Fineman M. A randomized, open-label, crossover study examining the effect of injection site on bioavailability of exenatide (synthetic exendin-4) Clin. Ther. 2005; 27:210-5.

Prospecto Glucagen Hypokit. Disponible en: http://www.novonordisk.es/media/Prospectos/Diabetes/GlucaGen_Hypokit1_mg.pdf.

Rosenbloom A L. Insulin injection lipoatrophy recidivus. Pediatric. Diabetes 2014; 15(1):73-74.

Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, Letondeur C, Sauvanet JP, Tubiana-Rufi N, Strauss K. Scientific advisory board for the third injection technique workshop. New injection recommendations for patients with diabetes. Diabetes Metab. 2010 Sep; 36. Suppl 2:S3-1.

Siminerio L, Pearson T, Kulkarni K, et al. Strategies for insulin injection therapy in diabetes self-management. The American Association of Diabetes Educators. 2011.

Lo Presti D, Ingegnosi C, Strauss K. Skin and subcutaneous thickness at injecting sites in children with diabetes: ultrasound findings and recommendations for giving injection. Pediatric Diabetes 2012, Vol. 13(7):525-33.

Hompesch M, Morrow L, Watkins E, Roepstorff C, Thomsen HF, Haahr H. Pharmacokinetic and pharmacodynamic responses of insulin degludec in African American, white, and hispanic/latino patients with type 2 diabetes mellitus. Clin. Ther. 2014. Apr 1; 36(4):507-15.

Roach P. New insulin analogues and routes of delivery: pharmacodynamic and clinical considerations. Clin. Pharmacokinet. 2008; (9):595-610.

Biester T, Blaesig S, Remus K, Aschemeier B, Kordonouri O, Granhall C, Søndergaard F, Kristensen NR, Haahr H, Danne T. Insulin degludec's ultra-long pharmacokinetic properties observed in adults are retained in children and adolescents with type 1 diabetes. Pediatr. Diabetes. 2014 Feb; 15(1):27-33.

Danne T. Flexibility of rapid-acting insulin analogues in children and adolescents with diabetes mellitus. Clin. Ther. 2007; 29 Suppl D:S145-52.

Wolnik B, Hak L. Multicenter, open-label, non-randomized, non-interventional observational study of safety of treatment initiation with a biphasic insulin aspart. Expert Opin. Drug Saf. 2013 Mar; 12(2):137-44.

Liebl A, Prusty V, Valensi P, Kawamori R, Christiansen JS, Palmer AJ, Balschmidt P, Ligthelm R, Mohan V. Ten years of experience with biphasic insulin aspart 30: from drug development to the latest clinical findings. Drugs. 2012 Jul 30; 72(11):1495-520.

Workman B. Safe injection techniques. Primary Health Care, 2000; 10:43-50.

Bain A, Graham A. How do patients dispose of syringes? Pract. Diabetes Int. 1998; 15:19-21.

American Diabetes Association. Recommendation 2014. Diabetes Care January 2014; 37(1):S14-S80. Disponible en: http://care.diabetesjournals.org/content/37/Supplement_1/S14.full

Guía de tratamiento para la diabetes tipo 2. Revista de la Sociedad Argentina de Diabetes 2010, 44(5), 358-384.

DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N. Engl. J. Med. 1993; 329:977-86.

UK Prospective Study (UKPDS) Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complication in patients with type 2 diabetes (UKPDS 33). Lancet 1998, 352:837-853.

Epidemiology of Diabetes Interventions and Complications (EDIC.) New England Journal of Medicine, 2005, 353(25), December 22.

Murray P, Chune GW, Raghavan VA. Legacy effects from DCCT and UKPDS: what they mean and implications for future diabetes trials. Curr. Atheroscler. Rep. 2010 Nov; 12(6):432-9.

Opiniones y recomendaciones. Tratamiento de la diabetes mellitus con insulina. Actualización año 2007. Sociedad Argentina de Diabetes. Integrantes: Costa Gil JE, Fuente G, Cagide AK, Salzberg S, Buso CJ, Tonietti M, Ozuna B.

Chance RE, Frank BH. Research, development, production and safety of biosynthetic insulin. Diabetes Care 1993; 16 (Suppl. 3): 133-42.

Kang S, Creagh FM, Peters JR, et al. Comparison of subcutaneous soluble insulin and insulin analogues. Diabetes Care 1991, 14:571-77.

Radzuk JM. Davis JC, Pye WS, et al. Bioavailability and bioeffectiveness of subcutaneous human insulin and two of its analogues. Diabetes 1997, 46:548-556.

Barlocco D. Insulin glulisine. Aventis Pharma. Curr. Op. Investig. Drugs 2003, Oct; 4(10):1240-4.

Pickup JC. An introduction to the problems of insulin delivery. In Pickup JC. Ed. Biotechnology of Insulin Therapy. Oxford Blackwell Scientific Publications 1991:1-13.

Starke AAR, Heinemann L, Hohmann A, et al. The action profiles of human NPH insulin preparations. Diabetic Med 1989; 6:239-44.

Lepore M, Pampanelli S, Fanelli C, et al. Pharmacokinetics and pharmacodynamics of subcutaneous injection of long acting human insulin, glargin, NPH insulin, and ultralente human insulin and continuous subcutaneous infusion of insulin lispro. Diabetologia 2000; 49:2142-48.

Bohem B, Home P, Behren C, Kamp N. Premixed insulin aspart 30 vs. premixed human insulin 30/70 twice daily: a randomized trial in type 1 and type 2 diabetic patients. Diabet. Med. 2002 May; 19(5):393-9.

Rolla AR, Rakel RE. Practical approaches to insulin therapy for type 2 diabetes mellitus with premixed insulin analogues. Clin. Ther. 2005 Aug; 27(8):1113.

Kann PH, Wascher T, Zackova V, et al. Starting insulin therapy in type 2 diabetes: twice-daily biphasic insulin aspart 30 plus metformin versus once-daily insulin glargine plus glimepiride. Exp. Clin. Endocrinol. Diabetes 2006; 114:527-32.

Bretzel RG, Nuber U, Landgraf W, et al. Once-daily basal insulin glargine versus thrice-daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents (APOLLO): an open randomised controlled trial. Lancet 2008; 371: 1073-84.

Harris S, Yale JF, Dempsey E, et al. Can family physicians help patients initiate basal insulin therapy successfully? Randomized trial of patient-titrated insulin glargine compared with standard oral therapy: lessons for family practice from the Canadian INSIGHT trial. Can Fam. Physician 2008; 54:550-8.

Oyer DS, Shepherd MD, Coulter FC, et al. A (1c) control in a primary care setting: self-titrating an insulin analog pre-mix (INITIATE plus trial). Am. J. Med. 2009; 122:1043-9.

Davies M, Storms F, Shutler S, et al. Improvement of glycemic control in subjects with poorly controlled type 2 diabetes: comparison of two treatment algorithms using insulin glargine. Diabetes Care 2005; 28:1282-8.

Selam JL, Koenen C, Weng W, et al. Improving glycemic control with insulin detemir using the 303 algorithm in insulin naive patients with type 2 diabetes: a subgroup analysis of the US PREDICTIVE 303 study. Curr. Med. Res. Opin 2008; 24:11-20.

Yki-Järvinen H, Juurinen L, Alvarsson M, et al. Initiate Insulin by Aggressive Titration and Education (INITIATE): a randomized study to compare initiation of insulin combination therapy in type 2 diabetic patients individually and in groups. Diabetes Care 2007; 30:1364-9.

Stratton IM, et al. United Kingdom Prospective Diabetes Survey (UKPDS) 35. BMJ 321; 405-412, 2000.

Bergenstal RM, Johnson M, Powers MA, et al. Adjust to targetin type 2 diabetes: comparison of a simple algorithm with carbohydrate counting for adjustment of mealtime insulin glulisine. Diabetes Care 2008; 31:1305-10.

American Diabetes Association. Standards of medical care in diabetes e 2013. Diabetes Care. 2013; 36(Suppl 1):S11-S66.

Descargas

Publicado

10-01-2023

Cómo citar

Commendatore, V., Faingold, C., Frechtel, G., Fuente, G., Linari, M. A., Musso, C., & Tonietti, M. (2023). Recomendaciones sobre técnicas de inyección y titulación de insulinas para personas con diabetes. Revista De La Sociedad Argentina De Diabetes, 49(1), 13–31. https://doi.org/10.47196/diab.v49i1.194

Artículos más leídos del mismo autor/a

1 2 3 4 5 6 > >>