The Indian Council of Medical Research (ICMR) on Wednesday issued a set of fresh guidelines for Type 1 Diabetes management, including insulin storage and mixing, and directions for needle and injection sites. The fresh guidelines come as the Covid-19 pandemic has disproportionately affected people with diabetes, exposing them to a high risk for severe illness and mortality. “All children and adults with type 1 diabetes (T1DM) require insulin as soon as they are diagnosed and continuously thereafter throughout life,” the medical body said in its updated guidelines.
Here is what the new guidelines say:
ICMR guidelines for storage of insulin
> At the time of purchasing the insulin, the expiry date should be checked and it should be ensured that there are no clumps or discoloration of the insulin.
> The unopened insulin vial or cartridge should be kept in the refrigerator shelf for long-term use. They should not be exposed to direct sunlight or never be frozen.
> Once opened, the insulin vial can be kept at room temperature for up to a month in cooler climates. In hotter climates, insulin can be stored in the refrigerator shelf. At room temperature – 25 degree Celsius – insulin will lose less than one per cent of its potency over a month, while at higher temperatures there will be a greater loss of potency.
> The latest guidelines say that insulin pens should never be stored with the needles attached since air may be drawn in.
Guidelines on insulin needles
The length of needles recommended by ICMR for injecting insulin in most children and adults is four to six millimeters. The insulin should be injected at an angle of 45 to 60 degrees instead of 90 degrees to avoid the risk of intramuscular injection.
Guidelines on insulin injection site
> The forearm and calves should never be used for insulin injections.
> In general, the same region should be used for injection at different times of the day. However, the exact sites should be changed daily by moving 0.5-1.0 inch from the previous site.
> Injections in the abdomen result in faster absorption and are less affected by exercise, hence the site is suitable for injecting faster-acting insulin preparations.
ICMR guidelines on insulin mixing
Regular and NPH (Neutral Protamine Hagedorn) insulin can be mixed for use in a syringe (split-mixed regimen). For this purpose, regular insulin should be drawn first followed by NPH insulin.
> Allow insulin vials to reach room temperature and check there are no clumps or particles.
> Turn the NPH bottle on its side and gently roll it between the palms. Do not shake vigorously as it may damage the vial.
> Clean the top of the vial with an alcohol swab. Take the NPH insulin vial and inject air equal to the required dose. Do not draw insulin yet. Remove the needle from the vial.
> Take the vial with regular insulin, clean top with alcohol and inject air of an amount equal to the regular insulin dose.
> With the needle still in the regular vial, turn the vial upside down and pull the plunger to fill the syringe with the desired dose. Remove any air bubbles from the vial.
> Re-insert the needle into the vial of NPH insulin, slowly draw the correct amount of insulin and remove the needle from the vial. The syringe is ready for injecting
In India, human regular and NPH insulin are available in strengths of 40 units/ml and 100 units/ml in vials. All insulin (regular, NPH, analogs) in pen cartridges have a strength of 100 units/ml.