2.
Putthecapped syringe intoa large plastic bottle such asthat used for bleach,bottled water, seltzer, or soft drink.
Alternativelyuse a large coffee can. 3.
When the container is fuU, replace the cover or cap and prevent its removalby applying duct tape. 4.
Put the container into your trash* or take it to your physician, hospital, or pharmacy for pickup by the special disposal service that they might use. 5.
Ifyouarein a hotel or restaurant, don'tput used syringes in their trash containers unless you first put them with needle recapped in an opaque plastic bag, sealed with tape or knotted closed.* Their cleaning people wiU not appreciate seeing loose syringes.
In an airplane, recap the needle and put the syringe in the trash bin in the lavatory.
A High-Tech Method It's now possible to meltneedles offinsulin syringes.
If you are espe ciaUy conscientious about our environment or would enjoy using a briUiant technological device, you might try the Disintegrator Plus.
This is a smaU device in a plastic box measuring about 6 x 3Vi x 2xh inches (15.24 x 8.9x 6.35 cm) and powered by a buUt-in rechargeable battery.
It seUs for$49 atCVS (cvs.com) andfor$79 ifpurchased from the manufacturer.
To operate the device you merely insert the needle into a hole and press ontheactivating button for 3seconds.
The needle wiU disappear,
Somecommunities forbidthe disposal of suchcontainers in local garbage. It is wise to contact your garbage coUection department foradvice. You canalso visit www.safeneedledisposal.org to access a national database of local regulations in the United States. f I save plastic grocery bags forthis purpose and always pack a few empty ones when I travel.
Insulin: The Basics ofSelf-Injection 261
melted into a tiny metal blob that is stored inside the instrument. You can then drop the plastic syringeinto your ordinary trash container. The stored metal blobs can be removed after a month or so by un screwing a small screw in a hatch on the bottom and pouring them out. This may take 30 seconds. Disintegrator Plus is distributed by Perfecta Products, Inc., of North Lima, Ohio, phone (800) 319-2225. It's fun to use and keeps needles off our beaches.
REMOVING BLOODSTAINS FROM CLOTHING
Nowadays, most of us will inject through thin clothing (shirts, stock ings, trousers) when it's inconvenient to undress.
This can cause a problem on the rare occasion that the needle encounters a small blood vessel.
A drop of blood can appear at the puncture site and stain your clothing.
Finger punctures sometimes bleed more freely than you ex pect, so that upon squeezing you mayget a squirt in the eye, or blood on your tie, if you're not careful.
The answer to bloodstains on clothing is hydrogen peroxide solu tion.
Hydrogen peroxide is very inexpensive and is sold in allpharma cies.
Purchase several small bottles.
Keep a bottle of peroxide handyat every location where you measure blood sugars.
Carry a small bottle in your luggage when you travel.
Once a bottle has been opened, the solution remains stablefor perhaps six months,so you might want to have a backup bottle available.
You can make bloodstains disappear very simply withoutbleaching the dyes in your clothing.
It'sbestif you treat the stain while the blood is still wet, as dried blood bleaches very slowly.
If you allowthe blood to dry, it may take 20 minutes of rubbing to get rid of the stain.
Pour some peroxide on a handkerchief and rub it into the stain.
The perox ide will foam when it contacts blood.
Keep applying and rubbing un til the stain has vanished.
SPECIAL DEVICES FOR "PAINLESS" INJECTIONS
Many devices have been advertised with the claim that they inject in sulin "without pain." Since most diabetics have not been taught the
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high-speed painless injection technique described in this chapter, manyof these special, spring-driven devices aresoldeveryyear.
Ifyour injections are already painless, it makes Uttle sense to usethem.
Other "painless" devices, caUed jet injectors, use very precise con struction to inject a high-pressure jet of insulin, penetrating the skin without a needle.
These injectors do not require a separate syringe since they must be loaded directly with insulin, using special adapters that plug into the insuUn vial.
Although the conceptis very enticing, sprayinjectors posesomeproblems.
First, they're veryexpensive, cost ingfrom$300 to $600 in the United States.
Although thisis a substan tial initial investment, the cost can be recovered over the course of a year or two if you're giving yourself lots of injections with disposable syringes.
Your insurance plan may not pay for a jet injector but wiU most likelypay for disposable syringes.
They'renot as convenient as disposable syringes because they must be taken apart and sterilized in boiling, deionized water everyone to two weeks.
Also, the adapters for the insulin vials sometimes leak when the vialsare carried in a purse or bag.
You wiU require considerable training and experimentation with pressure settings in orderto give yourself a properjet injection.
This can delaygettingyour blood sugars normalized.
You may also experi ence sUghtiy more pain than you would with a speedily injected shot from a conventional syringe, and there'sa high incidenceof blackand blue marks on the skin and minor bleeding and even loss of smaU amounts of insuUn at the puncture sites.
Despite these drawbacks, jet injectors do have two unique advan tages, aside from reducing the number of syringes you must dispose of.
Firstis that youwUl require about one-thirdless insulin, since the shots are better absorbed.
Second, if you use fast-acting insuUn to lower elevated blood sugars, it wiU work even faster.
But not faster than an intramuscular injection (page 307).
FinaUy, jet injectors should not be used for longer-acting insulins.
INSULIN PENS Several manufacturers are advertising "insuUn pens." These are sy ringes into which smaU cartridges of insulin can be loaded. They are intended to reUeve you of the burden of carrying a vial of insulin if you have to injectaway fromhome.None of thosemarketedas of this
Insulin: The Basics ofSelf-Injection 263
writing can be set at quarter-unit increments, and only one of those sold in the United States can be set at half-unit increments.
Most therefore cannot provide the fine-tuning ofblood sugars that ourreg imens require.
Stay away from them unless youareveryobese and re quire large doses of insulin.
With large doses, an error of Vi or Va unit is insignificant.
Thecartridges used for insulin pens areless than one-thirdthe size of standard insuUn vials and are consequently more convenient to carryin a pocket or purse.
You canpuncture thecap withthe needle of a standard insulin syringe andslowly draw out insulin.
Do notinject air or reinject insulin into these cartridges.
17 Important Information About Various Insulins
I f you start using insulin, you ought to understand how its effects can be controlled. It can do some remarkable things, but it must be handled with respect and knowledge. Much of the information in this chapter is based upon my experience with my own insulin needs and with those of my patients. Asin much of this book, you will likely note that some statements contradict traditional teachings and manufacturers' literature.
AVOID INSULINS THAT CONTAIN PROTAMINE There are a confusing number of brands and types of insulins being marketed today , andeven more areon theway.
Insulins maybe cat egorized by how long they continue to affect blood sugars after injec tion.
There are most-rapid-acting, rapid-acting, intermediate-acting, and long-acting insulins.
Until recently, the rapid-acting insulins ap peared clear, like water, and the other insulins appeared cloudy.
The cloudiness is caused by an additive that combines with the insulin to form particles that slowly dissolve under the skin.
The one remaining intermediate-acting insulin, called NPH, is modified with an animal protein caUed protamine.
Insulins that contain protamine may stimu late the immune system to make antibodies to insulin.
These antibod ies can temporarily bind to some of the insulin, renderingit inactive.
Then, unpredictably, they can release the insulin at a time when it's not necessarily needed.
This effect, although small,impairs the metic ulous control of blood sugars that we seek.
Protamine can present an-
Important Information AboutVarious Insulins 265
other, more serious problem ifyou ever require coronary angiography for the study of arteries that feed your heart (a common procedure nowadays).
Just before such a study, you would be given an injection of the anticoagulant heparin to prevent the formation of bloodclots.
When the procedure isover, protamine isinjected into a blood vessel to"turn off" the heparin.
This can cause severe aUergic reactions, even death, in a smaU percentage of people who have previously been treated withinsulin containing protamine.
Thus, even if an insulin is marketed as a "human" insulin, its effects upon antibody production may besignificant if it contains the animal protein protamine.
As you may guess, I strongly oppose the use ofinsulins containing protamine.
In the United States, theonly oneiscaUed NPH(elsewhere it may be caUed isophane insulin).
NPH or mixtures of NPH and other insulins are widely avaUable and should beavoided.
People who require very smaU doses of insuUn, such as chUdren, may be best treated with dUuted insulin (page 272) for accurate dose measure ment.
Unfortunately, there isnodUuting fluid made for glargine, one of our two remaining long-acting insulins.* I therefore am nowreluc tantly obUged to prescribe three daUy doses of dUuted NPH on rare occasions.
More commonly, however, I'U dUute thelong-acting insulin detemir with saline, as described on page 272.
A Ust of the insuUns that I consider possibly suitable appears on page 269.
STRENGTHS OF INSULIN
Thebiological activity of insulin is measured in units. At smaU doses, 2 units of insulin should lower blood sugar exactly twice as much as 1 unit An insulin syringe is therefore graduated in units, and the one shown in Figure 16-4 is also caUbrated in half-units. The lines are far enough apart so that even Va unit can be reasonably estimated. The sy ringe we recommend is designed for a concentration of 100 units per
*My favorite long- and intermediate-acting insulins, ultralente and lente, were taken offthemarket in 2006 because they were less profitable to themanu facturers. DUuting fluids were available for these insulins. Although theAmeri can Diabetes Association made no protest when these discontinuations were announced, there iscurrendy an uproar over this intrusion uponpatient care in the U.K.
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