The Pharmaceutical Journal
Vol 270 No 7236 p228
15 February 2003

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Letters to the Editor

Insulin labelling

Patients soon find their optimal injection technique

From Mr N. A. Caldwell, MRPharmS

I welcome the contributions from Gavin Miller (PJ, 14 December 2002, p845) and Irene Gummerson (PJ, 11 January 2003, p50) to the debate on how we label insulin preparations. I can see great sense in both commentaries. However, I would suggest that specifying how to inject an insulin preparation in terms of "subcutaneous", or "just under the skin", would not make a blind bit of difference to a diabetes patient who administers his or her medicine using a learnt technique. As someone who has injected insulin for the past 30 years I can attest to the fact that we soon find out our own optimal injection technique. If you go too deep and hit a muscle it hurts excruciatingly. If you hit a blood vessel it hurts excruciatingly. It is really quite simple.

I also disagree with labelling certain insulins to be injected before food, while others should be injected before meals. When is a gastronomic extravaganza a small snack, and thus merely food, and when does it become a meal? All meals, generally, contain food, but not all food is a meal. Why, then, draw the distinction on the label.

In addition, a number of patients on basal bolus regimens take a long-acting insulin preparation before bed, and not before meals, without ill effect. Therefore, should we be instructing that it must be taken before food, when many patients do not, and have not, had a problem, such as nocturnal hypoglycaemia, with injecting before bed?

I would propose therefore that we label long-acting insulin preparations (eg, Insulatard) with "Inject the required dose once or twice daily as directed".

For short- and intermediate-acting insulins (eg, Actrapid, Mixtards and Humulins) label with "Inject the required dose 20 to 30 minutes before food, as directed".

For rapid-acting insulins (eg, Novorapid, Humalog, NovoMix and Humalog Mix) label with "Inject the required dose immediately before food as directed".

I would suggest that what we "write" on the label is often for our own benefit and not implemented by a typical insulin-dependent diabetes patient.

I propose therefore that we should stop specifying the dose, which everyone agrees is a variable entity, and thus is silly to specify on a cartridge that will be used for a couple of weeks. In addition I think we should consign "subcutaneous" to the dustbin.

Neil Caldwell
Deputy Chief Pharmacist, Clinical Services,
Wirral Hospital NHS Trust

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