**9. Insulin analogs**

relatively high doses of glargine (>40 IU), with total daily dose (TDD) insulin up to 300 U daily. No differences between 4- and both 8- and 12.7-mm PNs in hypo- or hyperglycemic events or

was found to be less painful, easier to use, easier to insert, and less anxiety-provoking than 8 or

• The 4-mm needle inserted perpendicularly is long enough to penetrate the skin and enter the subcutaneous tissue, with little risk of intramuscular (or intradermal) injection. Therefore, it should be considered the safest pen needles for adults and children regardless of

• The 4-mm needle should be inserted perpendicular to the skin (at 90° to the skin surface),

• Very young children (6 years old and under) and very thin adults should use the 4-mm needle by lifting a skin fold and inserting the needle perpendicularly into it. Others may

• Patients with tremors or other disorders, which make them unable to hold a 4-mm pen

Recommended injection sites include the abdomen, lateral thigh, arms, and buttocks [34–38]. In the abdomen, injections or infusions in adults may be given within the following boundaries: 1 cm above symphysis pubis, 1 cm below the lowest rib, 1 cm away from the umbilicus, and laterally at the flanks. In the lateral thighs, patients should use the upper third anteriorly. The posterior lateral aspect of the upper buttocks and flanks may be used. In the arm, one may use the mid-third posterior aspect. In children, the abdominal boundaries are similar to adults, but 2 cm is used instead of 1 cm for all distances. A degree of clinical judgment must

Soluble human insulin (e.g., regular insulin) has a slower absorption profile than the rapidacting analogs (lispro, aspart, and glulisine). The PK and PD of regular insulin, as well as those of neutral protamine Hagedorn (NPH), are highly dependent on the body site injected

• IM injections of NPH and long-acting insulin analogs must be strictly avoided due to the

. The 4-mm needle

insulin leakage were found in obese subjects with BMI up to nearly 60 kg/m2

Based on these studies, FITTER recommended the following:

not at an angle, regardless of whether a skin fold is raised. A1.

inject using the 4-mm needle without lifting a skin fold. A1

needle in place, may need longer needles. B3

be used in all cases, adult and pediatric.

risk of hypoglycemia [17, 39–41]. **A2**

and the technique used. FITTER recommendations state that:

12.7 mm (all at p < 0.05).

62 Ultimate Guide to Insulin

**7. Injection site care**

**8. Human insulin**

age, gender, ethnicity, and BMI. **A1**

There are fewer studies of optimal delivery methods for the newer insulin analogs and GLP-1 s. However, insulin analogs are *not* as dependent on injection sites as are human insulins or NPH. From the existing studies, FITTER recommended the following:

