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Good Insulin Mixing Technique Improves Glycemic Control LONDON, UK -- November 5, 1999 -- In this week’s issue of The Lancet, Dr. Peter Jehle and colleagues from University Hospital, Ulm, Germany, report that inadequate resuspension of insulin in insulin pens is common. They also found that patients who improve their technique for mixing the insulin before injection have fewer hypoglycaemic (low blood sugar) episodes. Insulin pens are now the most widely used devices to deliver insulin. One of the most commonly used insulins, neutral protamine Hagendorn (NPH), is in a two-phase solution and needs to be resuspended, either by shaking, rolling, or tipping the pen before use. The researchers collected pen cartridges from patients in clinics, measured the proportion of NPH insulin, and asked the patients to complete questionnaires about their insulin technique. A random sample of patients was re-evaluated after further education about insulin resuspension. The researchers also used a mechanical device to tip an NPH-containing cartridge to assess the mixing of the NPH insulin. The investigators found that only 38 (35 percent) of 109 cartridges had values close (+/- 20 percent) to the ideal value. Very few patients (9 percent) tipped and rolled their pen more than ten times. Twenty cycles of tipping the pen by the mechanical device were needed before there was complete resuspension of the NPH insulin-a number substantially higher than is given in standard protocols for pen use. Of the 44 patients who were assessed after further education, suspension errors decreased in 35 patients. Although there was no change in glycosylated haemoglobin concentrations (a measure of long-term diabetes control) in the 35 patients with improved NPH insulin suspension, these patients had significantly fewer hypoglycaemic episodes than they had in the previous period. Inconsistencies in insulin dosage may be life-threatening. Hypoglycaemia is a barrier to achieving good blood-glucose control in some patients, and may be especially dangerous in elderly patients and in patients unaware of their hypoglycaemia. "We recommend that patients using insulin pens with NPH preparations tip the pen at least 20 times," say Dr Jehle and colleagues. E-mail this page to a friend or colleague! To print, use this version