1. Diabetes Survival Camp – Session 2
You can strive and thrive with diabetes
Welcome

2. Survival Camp Topics Training 2 Calibrate your Diabetes Compass
Boots are made for Walking!
Medications and Insulin

3. Diabetes ABC’s
A 1c
B lood Pressure
C holesterol

4. A1C Blood Test
KEY MESSAGE: The A1C test measures a person’s average blood glucose over the previous 2 to 3 months.
Supporting Points
The A1C test is used to monitor blood glucose control. The test measures the level of glycosylated hemoglobin, which forms when glucose binds to hemoglobin in red blood cells. Because the lifespan of red blood cells is approximately 120 days, the glycosylated hemoglobin level is a good measure of average blood glucose over the past 2 to 3 months.
The American Diabetes Association recommends an A1C goal of less than 7% for people with diabetes. In people without diabetes, the normal A1C level is below 6%. For most people with diabetes, the A1C test is recommended at least twice yearly. Some people are advised to have more frequent (quarterly) A1C testing. An A1C value of 8% or higher almost always necessitates a change in the person’s treatment plan.
The American College of Endocrinology (ACE) and American Association of Clinical Endocrinology (AACE) recommend an A1C goal of 6.5% or less. An ACE consensus panel recommended this lower A1C goal to further reduce the risk of complications in people with diabetes. The American Association of Diabetes Educators has stated its support of this lower A1C goal.* The ADA recommends considering more stringent A1C goals (normal A1C; less than 6%) in individual patients.
Keeping the A1C level within the goal range can prevent or delay long-term complications of diabetes. Improved glycemic control is associated with reduced risk of cardiovascular events and microvascular complications, such as retinopathy, neuropathy, and nephropathy. The United Kingdom Prospective Diabetes Study found that lowering blood glucose in type 2 diabetes with intensive therapy (median A1C of 7%) reduced overall microvascular complications by 25%. The Diabetes Control and Complications Trial found that for every 1% reduction in A1C, the risk of microvascular complications was reduced by 40% on average.
* Berkowitz KJ. AADE supports new guidelines for diabetes management. Diabetes Educator. 2002;28(1):26,29.

6. A1c and Mean Plasma Glucose
A1c (%) Mean Plasma Glucose
American Diabetes Association 2008

7. Know Your Check every 3 - 6 months
A1c
Less than 7%

8. Glucose Goals – How do we Get there?
Test
Pre-meal blood sugar
1-2 hours after meal blood sugar
Goal
70 – 130
Less than 180
Healthy Eating
Exercise
Medication / Insulin
Monitoring

9. Keep Your Blood Pressure In Check
KEY MESSAGE: In people with diabetes, blood pressure should be measured at each doctor’s visit and, if elevated, treated to reduce the risk of complications.
Supporting Points
Hypertension is extremely common in people with diabetes. Up to 60% of people with diabetes have hypertension, which is defined as a blood pressure of 140/90 mm Hg or higher. In type 2 diabetes, hypertension is often part of the metabolic syndrome of insulin resistance, which also includes hyperglycemia, obesity, and dyslipidemia. In type 1 diabetes, hypertension may signal the onset of diabetic nephropathy.
Controlling blood pressure reduces the risk of both macrovascular and microvascular complications. The UKPDS showed that for every 10 mm Hg decrease in mean systolic blood pressure, the risk of any diabetes complication was reduced by 12% and the risk of death was reduced by 15%.
Hypertension can be managed through lifestyle changes and, for many people, use of medications. Nondrug treatment usually includes weight reduction, dietary sodium restriction, and moderately intense physical activity, such as 30 to 40 minutes of brisk walking on most days of the week. Many people also need one or more daily medications to control high blood pressure. Angiotensin-converting enzyme (ACE) inhibitors are considered first-line drug therapy for most patients with diabetes, but many types of antihypertensive medications are available. The goal of treatment is to lower blood pressure to a target of 130/80 mm Hg or less.

10. UKPDS Blood Pressure Findings
By controlling your blood pressure you reduce your risk of:
Heart failure (56%)
Stroke (44%)
Death from diabetes (32%)

11. (check each office visit)
Blood Pressure Goal
Less than
130 / 80
(check each office visit)

12. Blood Fat (Cholesterol Goals)
Cholesterol Levels:
Check once a year
LDL (lousy cholesterol) less than 100
Less than 70 with heart disease
HDL (happy cholesterol) more than 40
Triglycerides (bad fat) less than 150

13. A 1c (less than 7%) B lood Pressure (130/80) C holesterol
Diabetes ABC’s
A 1c (less than 7%)
B lood Pressure (130/80)
C holesterol
(LDL <100, HDL > 40, Trig < 150)

14. How are you Kidneys Working?
Creatinine - a simple blood test to check your kidneys. Normal is less than 1.5.
GFR- Glomerular Filtration Rate – how well your kidneys are working.
Goal is more than 60
Talk to your doctor if less than 60

15. Flu Shot and Pneumonia Vaccine
If you have diabetes, you are more likely to get the flu.
Sign up for your flu shot in September.
Ask your doctor if you should also get a pneumonia vaccine.

16. Dental Care mouth infections more common
flushing, brushing, regular check-ups important!
See your dentist at least every 6 months.

17. Schedule Regular Visits with Diabetes Care Providers
KEY MESSAGE: Most people with diabetes should see their health care team at least twice a year for regular checkups and laboratory tests.
Supporting Points
Although guidelines need to be individualized, most people with diabetes are advised to have a blood test to measure A1C and a blood pressure check every 6 months. Some people with diabetes are advised to have an A1C test every 3 months. Because gum disease is more common in people with diabetes, regular dental visits (usually, twice a year) also are important.
At least once year, people with diabetes should have a blood test to measure lipids, a urine test to check protein, a comprehensive eye exam, and a complete foot exam. An annual flu shot is recommended. Advise people to check with their diabetes care team about other immunizations that may be recommended, such as the pneumococcal vaccine.

18. Mr. Jones -What Should We Do?
64 yr old with type 2 with heart problems
Labs:
A1c 9.3%
HDL 41mg/dl
LDL 156 mg/dl
Triglyceride 260mg/dl
Last eye exam, 1992
B/P 142/92
Self-Care Skills
Walks dog around block 3 x’s a week
Bowls every Friday
3 bottles of beer daily
Widowed, so usually eats out
15 lbs overweight

19. You Can Survive and Thrive with Diabetes
Steps
A1c less than 7%
Get blood pressure to goal
Get lipids to goal
Get active
Stop Smoking
Partner with your health care team
Attend our support group

20. Adopt a Healthy Lifestyle
KEY MESSAGE: By taking diabetes seriously and actively participating in self-care, people with diabetes can prevent or slow the development of complications.
Supporting Points
To prevent complications or slow their progression, people with diabetes should be encouraged to:
Keep blood glucose as close to normal as possible. Explain that intensive diabetes management to keep A1C below 7% has been proven to reduce complications. (Note that the American College of Endocrinology and the American Association of Clinical Endocrinologists recommend an A1C goal of 6.5% or less. The American Diabetes Association recommends considering more stringent A1C goals of less than 6% in individual patients.) People should see their health care provider regularly for checkups that include measurement of A1C, blood pressure, and blood lipids.
Make healthy food choices and engage in regular physical activity. These lifestyle changes can help people to lower their blood glucose, control their blood pressure, and improve their blood lipid profiles.
Quit smoking. People with diabetes who smoke need to be informed about the added health risks of this habit. Those who smoke should receive education on smoking cessation programs and techniques, including alternative nicotine delivery devices and local smoking cessation programs or support groups. Written or video educational materials also can be provided.

21. Boots are Made for Walking

22. Good News About Physical Activity
KEY MESSAGE: Regular physical activity provides numerous physical and psychological benefits for people with diabetes.
Supporting Points
An individualized plan of regular physical activity can help people with diabetes to:
Lose weight or maintain a stable body weight. Regular physical activity can enhance weight loss or aid in weight maintenance, especially when combined with an appropriate calorie-controlled nutrition plan. Physical activity helps the body burn more calories and may increase metabolism by building muscle mass.
Reduce the risk of cardiovascular disease. Regular physical activity strengthens the heart and blood vessels helping to lower blood pressure and heart rate, provides more oxygen to the blood, and improves blood lipids, especially high-density lipoprotein (HDL) cholesterol. These and other favorable effects of physical activity reduce the risk of heart attack and stroke.
Achieve better blood glucose control. During and after physical activity, glucose is removed from the blood for energy, which lowers blood glucose levels. Regular physical activity also can increase insulin sensitivity in target tissues, which may reduce or eliminate the need for diabetes medications in some people.
Improve physical and mental well-being. Patients who are physically active gain energy, strength, and stamina. Regular physical activity can boost self-esteem and reduce stress, encouraging people to take further positive steps toward diabetes self-management.

23. Physical Activity: Keep It Fun
KEY MESSAGE: By choosing a variety of activities and doing them at a comfortable pace, a fitness plan can be safe, effective, and fun.
Supporting Points
Activities should match a person’s interests and abilities. People are more likely to participate in regular physical activity if they enjoy it and find it convenient. Encourage people to talk or think about activities they enjoy or would like to learn, such as bicycling, dancing, tennis, or swimming.
Finding a fitness partner has several benefits. A partner can provide the support and encouragement to help a person with diabetes stay committed to regular physical activity. Also, a buddy who is aware of his or her partner’s diabetes can provide support in case hypoglycemia or other complications occur.
Participating in a variety of activities can prevent the doldrums. Trying alternate forms of activity adds interest to the routine and avoids putting strain on a particular part of the body. The physical activity plan can include recreational sports or hobbies, such as hiking or dancing, as well as everyday activities around the home, such as gardening, car washing, leaf raking, and dog walking.
Tip: In addition to asking people about the kinds of activities they enjoy, encourage them to consider how best to fit physical activity into their daily schedules. For example, many people can easily fit a walking program into their daily routines. Suggest ways that people can do more walking, such as by parking further from work or using the stairs instead of an elevator. In inclement weather, walkers can move indoors, such as inside a local mall or health club.

24. Activity Pyramid

25. Success with Exercise What kind of activities count as exercise?
What are some barriers to exercise?
How do you succeed with exercise?

26. Set a Realistic Exercise Goal
Set a realistic starting goal for YOU
3 ten minute segments a day
Long term goal – 30 min’s, 5 days a week
Start slow, increase gradually, listen to your body, do not overdo
Drink water before, during and after

27. Physical Activity Can Lead to Low Blood Glucose (Hypoglycemia)
KEY MESSAGE: People who take insulin or oral diabetes medications need to take precautions to avoid exercise-induced hypoglycemia.
Supporting Points
Blood glucose can fall during physical activity, increasing the risk of hypoglycemia. Blood glucose can continue to fall for some time after exercise is stopped, leaving a person vulnerable to late-onset hypoglycemia. Exercise-induced hypoglycemia is a special concern for people who take insulin or some oral diabetes medications (sulfonylureas or meglitinides).
People who are at risk of developing hypoglycemia during or after physical activity should be advised to:
Test blood glucose before, after, and, possibly, during physical activity. If blood glucose is low or if symptoms of hypoglycemia occur (e.g., feeling dizzy, shaking, or faint), stop the activity and test blood glucose. If this is not possible, treat symptoms and test as soon as possible.
Carry a carbohydrate-containing snack, such as glucose tablets or raisins. Consume 15 grams of carbohydrate to treat hypoglycemia, as needed. Then check blood glucose and, if needed, treat hypoglycemia again.
Exercise with a friend—ideally, a partner who knows you have diabetes. The partner should be instructed on what to do if symptoms of hypoglycemia occur. When exercising alone, people with diabetes should let someone know where they are going and when they expect to return.
Tip: People who have any diabetes complications need to talk to their doctor or exercise specialist about the safest and best forms of physical activity for them. For example, a person who has lost sensation in his feet may be advised to swim or use an exercise bicycle.

28. Tips for Safe Physical Activity
KEY MESSAGE: To prevent injuries and complications, people with diabetes need to take precautions to ensure safe physical activity.
Supporting Points
To ensure safe physical activity, remind people to:
Test blood glucose before and after physical activity. Exercising while blood glucose is outside the target range (too high or too low) increases the risk of acute complications. In people with type 1 diabetes, exercise can lead to hyperglycemia and ketoacidosis, especially if the blood insulin level is low. Exercise also increases the risk of hypoglycemia, especially in people who use insulin or some oral diabetes medications (sulfonylureas or meglitinides).
Always warm up and cool down. Before physical activity, people should warm up with easy, low-intensity movements. Once muscles are warm, gentle stretching is recommended. When ready to cool down, the activity should not be stopped abruptly. Rather, advise people to slow down the activity, then stretch their muscles again while they are still warm.
Reduce the risk of injury with appropriate clothing and equipment, including well-fitting athletic shoes and absorbent socks. People with diabetes should examine their feet daily and after physical activity to check for redness, blisters, cuts, and sores. Advise them to check inside their shoes before wearing and remove any foreign objects, such as a pebble.
Prevent dehydration. People should begin physical activity well hydrated, and replace body fluids during activity. Water is the best fluid replacement. Adequate hydration helps to prevent muscle cramping and maintain body temperature and blood volume.
Wear or carry diabetes identification, such as a Medic Alert bracelet or an information card that can assist with treatment should an emergency occur. Also, advise people to bring money for a phone call or consider carrying a cell phone during physical activity.
Tip: During physical activity, a person should be able to sing or carry on a conversation with a partner. If a person is too short of breath to talk during the activity, he or she may be overdoing it and should slow down or rest briefly.

29. Exercising Safely Let someone know your route Talk/Walk Test
Effects of exercise/activity can last hours
Keep in contact with your doctor for medication changes (blood sugars may decrease)

30. Exercise is Restorative
Regular physical activity reduces your risk of many chronic diseases and improves your overall quality of life.

31. Medications and Insulin
Your survival tools.

32. Medications Overview of Medications Section
All people with type 1 diabetes and many people with type 2 diabetes need medication to control blood glucose. For people who need medications, the dosages and types of drugs that are prescribed often change over time.
In the last decade, a number of new medications to treat diabetes have become available, and more are in the pipeline. For example, in people with type 2 diabetes, insulin sensitizers are available to treat insulin resistance, alpha-glucosidase inhibitors can reduce the after-meal rise in blood glucose, and meglitinides increase insulin release in response to food.
To ensure safe and effective use of medications, people with diabetes need ongoing education. A diabetes educator can explain the basics of how a given medication works, why it was prescribed, and how and when to take it. People who use medications also need to know when and how to report side effects.
A pharmacist who is knowledgeable about diabetes is a valuable member of the health care team. A growing number of pharmacists are CDEs. Regular education by a pharmacist or other CDE can help people with diabetes learn the skills to keep blood glucose within their target ranges. This is especially important for people who require complex medication regimens to control high blood glucose and other diabetes-related problems.
Further Readings
American Diabetes Association. Position statement. Insulin administration. Diabetes Care. 2004(suppl 1);27:S106–S109.
Cefalu WT. Novel routes of insulin delivery for patients with type 1 or type 2 diabetes. Ann Med. 2001;33:579–586.
Franz MJ, ed. Diabetes Management Therapies. A CORE Curriculum for Diabetes Education. Vol. 2. 5th ed. Chicago, Ill.: American Association of Diabetes Educators; 2003.

33. Oral Diabetes Agents:
Diabetes medications can be used by themselves, with other medications or with insulin
Using different types of medications together may work better.
Most lower A1c %

34. 5 Classes of Medications for Type 2
1. Increase insulin release from pancreas
2. Decrease sugar release from liver
3. Slow down the breakdown of starches in gut
4. Make your own insulin work better
5. Makes you feel fuller

35. Oral Medications for Type 2 Diabetes: Sulfonylureas
KEY MESSAGE: For people with type 2 diabetes, sulfonylureas can help to lower blood glucose, but care must be taken to prevent hypoglycemia.
Supporting Points
Sulfonylureas lower blood glucose by stimulating the pancreas to release insulin. These drugs work only in people whose pancreatic beta cells are still able to make insulin. Prescribed brands are Amaryl (glimepiride), DiaBeta, Glynase, Micronase (glyburide), Glucotrol, and Glucotrol XL (glipizide). A first-generation sulfonylurea, Diabinese (chlorpropamide), is available but no longer widely prescribed.
Sulfonylureas increase the risk of hypoglycemia, especially if a person skips a meal, drinks too much alcohol, or engages in physical activity that is more strenuous than usual. People who take sulfonylureas should watch for hypoglycemic symptoms and be prepared to treat hypoglycemic episodes, if they occur.
Some people are allergic to sulfa drugs and need to avoid sulfonylureas. In these situations, another diabetes medication may be prescribed.

36. Oral Medications for Type 2 Diabetes: Meglitinides
KEY MESSAGE: For people with type 2 diabetes, meglitinides can help to lower blood glucose, especially after meals.
Supporting Points
Meglitinides stimulate the pancreas to release insulin in response to eating a meal. Surges in blood glucose after eating often go undetected and have been shown to contribute to increased A1C levels. These medications reduce elevated blood glucose after a meal (postprandial hyperglycemia). Prescribed brands are Prandin (repaglinide) and Starlix (nateglinide).*
Meglitinides are taken before each meal, usually about 15 minutes before eating. Doses usually are taken two to four times a day, depending on a person’s meal pattern and other factors.
Like sulfonylureas and insulin, meglitinides (especially repaglinide) increase the risk of hypoglycemia. People who use meglitinides need to watch for symptoms of hypoglycemia and take steps to prevent this complication or treat it promptly at the first sign of low blood glucose.
* Note: Although repaglinide and nateglinide are both meglitinide analogues with similar mechanisms of action, these two agents differ chemically. Repaglinide is a benzoic acid derivative and nateglinide is a D-phenylalanine derivative.

37. Oral Medications for Type 2 Diabetes: Biguanides
KEY MESSAGE: For people with type 2 diabetes, metformin can help to lower blood glucose and reduce insulin resistance.
Supporting Points
Metformin lowers blood glucose primarily by reducing glucose production in the liver. Metformin also lowers insulin resistance in muscles and fat cells. Some people experience slight weight loss during metformin therapy. Metformin (Glucophage, Glucophage XR) is the only prescribed medication in a class of drugs called biguanides.
Metformin is often used in combination therapy and three combination medications are available. Glucovance contains metformin and glyburide, a sulfonylurea. Metaglip contains metformin and glipizide, a sulfonylurea. Avandamet contains metformin and rosiglitazone, an insulin sensitizer. Although metformin alone does not increase the risk of hypoglycemia, combination therapy with a sulfonylurea does increase this risk.
Metformin may cause diarrhea or an upset stomach in some people. However, this side effect often goes away in time and may be improved by taking the drug with food. Another approach to reducing digestive side effects is to begin therapy with a low dose and gradually titrate up, as tolerated, to an effective dose.
Rarely, metformin may cause lactic acidosis, a dangerous, potentially fatal buildup of lactic acid in the blood. For this reason, metformin is not indicated in some people, including those with kidney problems, liver disease, and who take medication for heart failure. People who use metformin are advised not to drink alcohol, which increases the risk of lactic acidosis. Before beginning metformin therapy, the physician may recommend checking kidney function with a creatinine test.

38. Oral Medications for Type 2 Diabetes: Alpha-Glucosidase Inhibitors
KEY MESSAGE: For people with type 2 diabetes, alpha-glucosidase inhibitors work in the intestine to reduce glucose absorption.
Supporting Points
Alpha-glucosidase inhibitors slow the digestion of carbohydrates in the small intestine. These medications work by inhibiting enzymes in the intestine that break down carbohydrates, so glucose levels rise more slowly after eating. Prescribed brands are Precose (acarbose) and Glyset (miglitol).
Some people who take these medications experience intestinal gas, bloating, and diarrhea. However, these side effects often diminish with continued use or dosage adjustment.

39. Oral Medications for Type 2 Diabetes: Insulin Sensitizers
KEY MESSAGE: Insulin sensitizers reduce insulin resistance, a major cause of type 2 diabetes.
Supporting Points
The insulin sensitizers (also called thiazolidinediones or TZDs) reduce insulin resistance. By facilitating insulin action and allowing glucose to enter cells more easily, these drugs help lower blood glucose levels. Prescribed brands are Avandia (rosiglitazone) and Actos (pioglitazone).
Very rarely, insulin sensitizers can cause serious damage to the liver. People who take insulin sensitizers need regular blood tests to monitor the health of the liver. Blood tests to check liver function should be performed before the medication is started, every 2 months for the first year, and periodically thereafter. In addition, people should tell their doctors if they have liver disease or if they experience signs of liver problems while taking an insulin sensitizer, such as unexplained tiredness, dark urine, or yellowing of the skin.
Some people may experience tiredness, weight gain, or swelling of hands and feet while taking insulin sensitizers. A person who experiences an unusually rapid increase in weight, swelling, or shortness of breath while taking an insulin sensitizer should contact the health care team immediately.

40. 5. New Diabetes Medications that make you feel “fuller”
Incretin Mimetics
Exenatide (Byetta)
Liraglutide (Victoza)
DPP-4 Inhibitor
Januvia (sitagliptin)
Onglyza (saxagliptin)
Amylinomimetics
Pramlintide (Symlin)

41. Human Incretin Hormone GLP-1
Brain
promotes satiety and reduction of appetite
Liver reduces glucose production
Stomach slows emptying
Alpha cell blocks glucagon secretion
Beta cell
stimulates insulin secretion

42. Gut Hormone Replacement Exenatide and Liraglutide
Most common side effects
Nausea, vomiting, diarrhea, dizziness, headache, feeling jittery, and acid stomach
Nausea is most common when first starting but decreases over time in most patients
Reduced appetite
Report any abdominal pain

43. DPP-IV Inhibitors – Januvia and Onglyza
Januvia (sitagliptin)
Onglyza (saxagliptin)
Lowers blood glucoses by increasing amount of gut hormone in your system
Januvia dose is 100 mg a day
Onglyza dose is up to 5 mg a day
Side effects: Can cause headache and flu like symptoms. Take lower dose if have kidney problems

44. Right Medication for You
Work with your health care team to determine which medications and/or combinations of medications are right for you.
Consider:
Blood sugar effect
Other side effects
Ease of use for YOU

45. Diabetes Medications
KEY MESSAGE: Everyone with type 1 diabetes and many people with type 2 diabetes need daily medication, in addition to regular physical activity, healthy food choices, and self-monitoring of blood glucose.
Supporting Points
All people with type 1 diabetes require daily injections of insulin, because their pancreas no longer makes insulin. (Oral diabetes medications generally are not indicated in people with type 1 diabetes.) At this writing, insulin can be administered only through injection or an insulin pump. However, new routes of insulin delivery are under development and educators are encouraged to keep up to date with progress in alternative insulin delivery routes.
For type 2 diabetes, medications are prescribed if lifestyle changes alone are not sufficient to control blood glucose. Once medications are prescribed, people need to continue their healthful lifestyle habits, such as meal planning, physical activity, and maintaining a healthy body weight. Medication selection depends on the person’s clinical presentation and underlying metabolic defects, such as the presence of significant postprandial hyperglycemia and the ability of the pancreas to produce insulin.
A person’s medication needs may change over time. For example, as type 2 diabetes progresses, management often shifts from lifestyle changes alone to include one or more oral medications, insulin, or a combination of these medications. Conversely, the need for diabetes medication sometimes can be reduced or even eliminated by attaining a healthy body weight, making healthier food choices, and engaging in regular physical activity.
Many people with type 2 diabetes require combination therapy, which uses two or more medicines to help control blood glucose, such as two or more oral medicines or oral medicine(s) plus insulin. In addition, many people need other types of medications to help control high blood pressure or high blood cholesterol or aid in weight loss or smoking cessation.

48. Invention of Insulin 1921
The first stills used to make insulin (early-mid 1920's).

50. Physiologic Insulin Secretion: 24-Hour Profile50
Insulin
(µU/mL)
Meal Insulin 25
Basal Insulin
Breakfast Lunch Dinner
150
Meal Glucose
Glucose
(mg/dL)
100 50
Basal Glucose 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
A.M.
P.M.
Time of Day

51. Insulin Action Categories
Bolus: lowers after meal glucose levels
Rapid Acting
Aspart, Lispro, Glulisine
Short Acting
Regular
Basal: controls glucose between meals, hs
Intermediate
NPH
Long Acting
Detemir (Levemir)
Glargine (Lantus)

52. Insulin Injection Sites
KEY MESSAGE: People who use insulin can make choices about how and where to inject insulin.
Supporting Points
Insulin is normally injected using a syringe with a very small needle. It also can be taken with a jet or pen injector. People need to be taught how to inject insulin by a qualified health professional.
Several areas of the body are usually suitable for insulin injection. These include the abdomen (except for a 2" circle around the navel), the top and outer thighs, and the backs of the upper arms, hips, and buttocks. Insulin injected in the abdomen usually is absorbed fastest. People who need insulin generally can choose any of the preferred areas for injection.
Within a chosen area, it is best to rotate injection sites. Rotating sites within a chosen area provides more consistent absorption of insulin, which is absorbed at varying rates in different parts of the body. (However, insulin glargine does not display different absorption rates at different sites.) Site rotation also can prevent local reactions, such as irritation and lipohypertrophy at the injection site. If lipohypertrophy occurs, changing to a new injection site may cause more rapid insulin absorption, necessitating a dosage reduction. A diabetes educator can help people select sites for insulin injection and provide guidance on rotating sites.
Tip: Many people fear using insulin because they believe shots are painful. Explain that modern technology has improved insulin needles so that many people hardly even feel the injection. Discuss products that can make insulin injection easier, such as jet injectors, which use high pressure to pass insulin through the skin, and pen injectors, which are conveniently portable.

53. Insulin Needles and Pens

54. Care for Insulin and Needles
KEY MESSAGE: Proper handling and storage of insulin and appropriate needle disposal are important for safe insulin therapy.
Supporting Points
Advise people to check the insulin bottle before use. Regular insulin, insulin lispro, insulin aspart, and insulin glargine should be clear with no floating particles or color. NPH or Lente insulin should be cloudy, with no floating pieces or crystals on the bottle. Also, remind people that insulin should not be used past its expiration date. Advise them to follow the manufacturer’s directions about when to discard an insulin vial after opening or an insulin pen or cartridge after first use.
Insulin should not be stored at very cold (less than 36ºF) or very hot (over 86ºF) temperatures, because temperature extremes destroy insulin. Teach people not to store insulin in the freezer, direct sunlight, or glove compartment of the car. Insulin should not be stored in damp places. Insulin should not be shaken or handled roughly, which may make it more likely to clump.
Teach people to dispose of used syringes and other medical waste properly. Demonstrate how to safely clip needles from used syringes or dispose of needles in a puncture-resistant disposal container. Advise people to check with their refuse companies or local waste authorities for proper disposal guidelines.

55. Safe Disposal of Syringes and Lancets
Take to Hazardous Waste Collection Site
In Paradise American Way (near Clark Rd.)
Monday- Friday, Hours-8am – 5pm. Phone
In Chico Marauder Street (near the airport)
Hours – 9am – 1pm on Friday and 9-4pm on Saturday
More info - Call (866)
Or Get BD Safe Clip