Insulin Time Action

Type of                                 Begins        Main                     All
Insulin                                  Working      Effect                   Gone

Fast-Acting (Clear)
Humalog/Novolog/Apidra®    <15 min.       ½ – 1 ½ hours       3 – 4 hours

Intermediate-Acting (Cloudy)
NPH                                       1 – 2 hours  3 – 8 hours            12 – 15 hours

Long-Acting (Clear)
Lantus®                                 1 – 2 hours  2 – 22 (No Peak)   24+ hours
Levemir®                               2 hours        No peak                 Up to 24 hours

Insulin Storage and Use

Vial

Unopened—store in the refrigerator
Opened—may store refrigerated or at room temperature, discard after 30 days

Cartridges

Unopened—store in the refrigerator
Opened—keep in the pen, discard after 30 days

I need to get new insulin when:

• the vials, pens or cartridges have been used longer than 30 days
• the insulin froze
• the insulin sat in a hot car for any length of time
• the cloudy insulin clumps or doesn’t mix in when rolled (if on NPH)
• I accidentally injected clear insulin into the cloudy vial or vice versa (if on NPH)

Mixing Insulin

When mixing insulin, please follow these directions:

1. Wash hands.
2. Collect insulin bottles, syringe, and alcohol swab.
3. Roll cloudy insulin between hands. Never shake bottles.
4. Wipe tops of insulin bottles with alcohol swab.
5. Inject air into cloudy insulin bottle and remove needle.
6. Inject air into clear insulin bottle. Leave the needle in the bottle and turn upside down.
7. Pull up and down on plunger to coat syringe with clear insulin. Make sure there are no air bubbles, then set plunger on correct dose.
8. Remove needle from clear insulin and insert into cloudy insulin.
9. Turn upside down and carefully pull plunger down to the total dose of insulin. Remember to NEVER push back into bottle after you have already mixed!
10. Remove syringe from cloudy bottle. Do not touch anything with the needle.
11. Select the site for injection and wipe with alcohol.
12. Pinch up the skin, insert the needle all the way in. Push the plunger all the way in. Let go of your pinch before you pull the needle out. This will prevent insulin from leaking back out.

Hints

• Remember you always draw up clear before cloudy.
• Another way to remember this: you always want a CLEAR day before a CLOUDY day!
• Also, "when in doubt, throw it out." If you overdraw insulin you need to start over.

Troubleshooting Insulin Injections

Leak back: Insulin leaks out of the injection site.

Solution: Be sure to release the pinch before pulling the needle out of the skin. If the leak back continues, then once the insulin is completely injected, release the pinch and count to five before pulling the needle out. This should allow the fat layer below the skin to accept the insulin more easily.

Bleeding: Blood leaks out of the injection site.

Solution: When giving the injection, be sure to stay away from visible capillaries just under the skin. If one of these is ‘hit’ with the needle, you will have a drop of blood come from the injection site. Occasionally you will still get a little bleeding from the injection site, but it should not occur routinely.

Bruising: A bruise will form under the skin following injection.

Solution: Be sure to follow the guideline as stated above for bleeding. Also make sure that an adequate pinch is being used to put the needle into the skin for the injection. If the needle gets too close to the muscle under the fat layer, then bruising may occur more often.

Pain: Your child complains of pain during or after injection.

Solution: If your child is complaining of much pain with injections, review your injection techniques to make sure that each step is being followed. Talk with the diabetes educator about this so that additional techniques may be tried to reduce this discomfort.

Hiding from the caregiver at ‘shot’ time: Children may react to injections in a negative way. Your child may try to hide or lock themselves in a room when it is time for an injection.

Solution: 

• Positive reinforcement (i.e. stickers, a stick of gum) for getting an injection without hiding.
• Encourage the child to participate in the process (i.e. help get the supplies, pinch up the skin for the parent to give the injection).

Insulin Pens

Insulin pens provide another way to inject insulin without using an insulin vial and a syringe. The insulin is contained in a 300 unit cartridge. Instead of drawing down to the correct line on the syringe, you can just turn a dial on the pen to the correct number. Just add the pen needle, and you’re ready for an injection.

These are some of the insulin pens that are available.

NovoPen Junior                     Lantus SoloStar
Novolog FlexPen                   Levemir FlexPen
Humalog KwikPen                  Apidra Flexpen
HumaPen Luxura

The Novolog FlexPen, Humalog KwikPen, Lantus Solostar, Levemir FlexPen and Apidra Flexpen are disposable and are thrown away when the insulin is all gone or when it has been used for 28 days; whichever comes first. The other pens are permanent pens that use replaceable insulin cartridges. The cartridges are also used for 28 days or until empty, whichever comes first. The Novopen Junior and the Humapen Luxura measure in half units.

Most insulin pens are good for 28 days once opened. NPH pens are good for 14 days ONLY and the Levemir FlexPen is good for 42 days.

Pen needles come in the 4 mm-Nano size, the 5 mm-No Pinch size or the 8 mm size.

Using Insulin Pens

1. Wash hands.
2. Take lid off insulin pen.
3. Wipe off top with alcohol swab.
4. Put needle on (make sure it is on tight) and take both caps off.
5. Dial an air dose great enough to see a few drops of insulin (usually 1 or 2 units unless using a brand new cartridge).
6. Hold pen upright and push out air until you see a few drops of insulin.
7. Dial your child’s dose.
8. Select the site for injection and wipe with alcohol.
9. Pinch up the skin, insert the needle all the way in. Push the plunger (top of pen) in all the way (make sure it is back to 0). Wait 5 seconds. Take thumb off plunger. Release pinch before you pull the needle out. This will prevent insulin from leaking back out
10. Put the big, clear needle cap back on and unscrew needle and place in sharps container.

Insulin Pumps

Insulin pumps are another way to dispense insulin. People on insulin pumps only use rapid acting insulin (Novolog, Humalog, or Apidra). When an insulin pump is used, insulin is put into a special syringe, which is then placed within the pump case. A cannula is then inserted under the skin (same sites as for injections), and insulin is infused through the cannula. Tape is placed over the cannula set to keep it in place for up to three days.

The pump is programmed to give a preset amount of rapid acting insulin at regular intervals (called the basal rate). Each time the person eats, he or she must enter the carb amount into the pump and have the pump give a “bolus” insulin dose. The endocrinologists at Riley Hospital typically do not place a patient on the pump before having diabetes for one year. The child and family go through extensive training on their pump with the pump nurse before using it.