, 2025-05-02 10:55:00
An international expert panel has recently released a comprehensive set of recommendations for optimal insulin injection techniques and equipment.
The group, called the Forum for Injection Technique and Therapy Expert Recommendations (FITTER), last issued recommendations for insulin injection practices in 2016. The new document, part of the group’s “FITTER Forward” initiative, “provides an updated rationale for the importance of proper injection technique training and its impact on diabetes management,” they wrote.
The writing panel, composed of 16 diabetes specialist physicians and allied health professionals from 13 countries, was led by David C. Klonoff, MD, medical director of the Dorothy L. and James E. Frank Diabetes Research Institute of Mills-Peninsula Medical Center, San Mateo, California, and clinical professor of medicine at the University of California, San Francisco.
“Overall, FITTER Forward aims to better equip healthcare professionals (HCPs) to advance diabetes care by empowering people with diabetes and their caregivers to correctly and safely deliver insulin,” Klonoff and colleagues said in the document, Advance Insulin Injection Technique and Education With FITTER Forward Expert Recommendations, published in the April 2025 issue of the Mayo Clinic Proceedings.
The recommendations are organized into four sections:
- Foundational science informing injection device design, experiences, and outcomes
- Proper injection technique procedures for insulin pens and syringes, from insulin storage to needle disposal
- Lipodystrophy risk reduction, with a focus on lipohypertrophy
- Structured injection technique training programs for people with diabetes
“Insulin therapy will have limited/unpredictable effects if not delivered properly. Therefore, time spent by HCPs and [people with diabetes]/caregivers on injection technique education is essential for improving clinical outcomes and reducing healthcare costs,” authors of the study wrote.
Section 1 advises that insulin should be injected subcutaneously rather than intramuscularly to avoid hypoglycemia. “Healthcare professionals should understand how the design of insulin delivery devices (especially needles) interplays with technique and physiology to affect injection force/pain/outcomes,” Klonoff and colleagues wrote.
All needles used for insulin delivery must be long enough to reliably administer insulin to the subcutaneous adipose tissue but short enough to avoid accidental intramuscular injection. HCPs are advised to discuss the pros and cons of various needle lengths with patients or their caregivers to determine individual needs.
Section 2 covers insulin storage and handling as well as injection technique procedures. Skin sites used for injection must have sufficient subcutaneous fat, and these areas should be rotated to avoid lipodystrophy. Separate detailed instructions are given for proper injection techniques with pens and with syringes. These have not changed since the previous FITTER recommendations, the authors noted.
Postinjection best practices include removing the pen needle from the pen after each use and not reusing pen needles or syringes. However, the guidance acknowledges that needle reuse is a common practice worldwide and may be necessary in some circumstances. HCPs are advised to educate patients about the consequences of reusing needles and to recommend that they carry sufficient backup supplies.
The document also addresses non-insulin injectables including glucagon-like peptide 1 receptor agonists and glucagon. Some patients will have initially learned injection techniques with these agents prior to starting insulin and may be using both simultaneously. Recommendations for needle length, site selection, and rotation are the same for these as for insulin, the authors said.
Section 3 focuses in detail on lipodystrophy, a fat tissue disorder that can arise from repeated injections into the same skin site. This in turn can lead to erratic insulin absorption with increased risks for both hyper- and hypoglycemia. The most common type of lipodystrophy is lipohypertrophy, involving enlargement of adipocytes, presenting as swelling/nodules.
A meta-analysis of 37 studies demonstrated that lipohypertrophy was associated with significantly worse A1c, greater glycemic variability, and higher total daily insulin doses. “Therefore, it is critical that HCPs explain the importance of lipohypertrophy risk reduction and encourage [people with diabetes] to take an active role in self-detection. Lipohypertrophy detection should be a routine part of diabetes-related complication assessment,” Klonoff and colleagues recommended.
Section 4 covers “pharmacoadherence.” Providers should ensure that the patient receives adequate education and support when starting insulin therapy, including addressing anxiety. The section provides educational strategies and warning signs that a review of injection technique might be warranted. Providers are advised to review reports from continuous glucose monitoring to make sure the patient’s glucose levels are consistent with their prescribed regimen.
The statement ends with a note that the guidance is meant to be used globally, regardless of socioeconomic status or geographic region. “We encourage HCPs, healthcare authorities, payers, and manufacturers to take action to support equitable resource allocation and access to evidence-based injection education,” Klonoff and colleagues wrote.
They concluded, “There is great opportunity to improve diabetes management through responsive collaboration and optimizing the basics of injection technique using the FITTER Forward recommendations. Equipped with these updated insulin injection technique recommendations and strategies for education, HCPs can improve the likelihood that their patients optimally use insulin with minimal complications.”
The FITTER Forward advisory board was funded by embecta, a manufacturer of injecting devices. FITTER Forward members received an honorarium from embecta for their participation in the advisory board but not for manuscript development. Klonoff has served as a consultant for Afon Technology, Atropos Health, embecta, Glucotrack, Lifecare, Novo Nordisk A/S, Samsung, SynchNeuro, and Thirdwayv and has participated on the data monitoring board for Fractyl Health.
Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.
