Injection Therapy Recommendations for People Living with Diabetes

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This article summarises the Forum for Injection Technique and Therapy Expert Recommendations (FITTER), the latest series of scientific seminars for injection techniques and therapies. The new recommendations are based on the results of the largest injection study in the world, which included 13,264 patients from 42 countries.

There are 3 new sets of international recommendations, which include insulin injection technique, insulin infusion technique and safety when administering insulin.

These recommendations regarding injection technique and safety are invaluable for health professionals working with clients using insulin, as they have proven to improve clinical outcomes. These include:

  1. Reduced HbA1c
    1. Reduced long term glycaemic-related microvascular, macrovascular and neurovascular complications
    2. Reduced need for referral to specialist care
  2. Reduced risk of unexplained hypoglycaemia
    1. Lower ambulance costs
    2. Reduced accident and ED admissions
    3. Reduced unplanned hospital admissions
    4. Reduced visits to primary care services
    5. Reduced need for referral to specialist care
  3. Reduced the risk of glycaemic variation
    1. Reduced risk of all the above
  4. Reduced insulin use to improve outcomes
    1. Improved clinical outcomes
    2. Reduced burden on the healthcare system and providers
    3. Lower overall costs
  5. Improved clinician and patient safety
    1. Safer environment
    2. Better outcome for all.

Three key conclusions from FITTER included:

  1. Health professionals are encouraged to suggest that clients change from longer needle lengths (8-12mm ) to 4-5mm needle length. The Injection Technique Questionnaire sent to the 13,264 patients indicated that 30% were now using the 4mm needle. Skin thickness was shown to be the same across the population, while subcutaneous tissue varies from patient to patient. 4-5mm needles must be injected at 90 degrees to avoid intradermal injection. Use of 8-12mm needles increase the risk of intramuscular injection, resulting in faster absorption of insulin and increased risk of hypoglycaemia.
  2. Lipohypertrophy should be actively prevented to avoid negative effects on insulin levels. Lipohypertrophy is the enlargement of the fat cells, and not always noticeable. It can be a complication of poor site rotation and needle reuse. Lipohypertrophy can lower the bioavailability of insulin by 20%, which reflects in clinical variability of blood glucose control and often requires the use of 10% more insulin. Randomised studies support the use of 4-5mm needles in the prevention of lipohypertrophy in association with site rotation. Observation and careful palpation of the injection sites is recommended to assess lipohypertrophy.
Lypohypertrophy, courtesy of Merle Taylor, Black Swan Health Credentialed Diabetes Educator

Lipohypertrophy is clearly evident in the images above, however it is NOT always this visible.







  1. Use a checklist to review the client’s injection technique, storage and disposal of insulin and insulin needles and paraphernalia. A checklist will identify areas that require education and changes to behavior to make insulin therapy optimal and safe. Health professionals should watch the client prepare and administer the injection, taking note of the site used. They can also ask more specific questions of the client, for example “how often do you rotate your sites?” and “what is the size of the area you are using?”. Record the outcomes/findings in the client notes for future review.Consider using this checklist from the Australian Diabetes Educators Association to improve evaluation of patient technique today.

The FITTER guidelines can be found online to guide health professionals through the optimisation of injection therapy. Click here to view the guide or click here to find out more about our range of free programs, led by our team of Credentialed Diabetes Educators, Accredited Practicing Dietitians and more.