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Do we need to get FITTER?

Debbie Hicks

Debbie Hicks reflects on a recent conference on injection technique in people with diabetes.

The Forum for Injection Technique and Therapy Recommendations (FITTER) congress, which took place in Rome in October 2015, marked a major milestone in the history of diabetes care. The FITTER congress presented delegates with an opportunity to improve the lives of people with diabetes through learning about safe insulin delivery. FITTER delivered on its primary objective, with the creation of a 90-page, evidenced-based and data-driven set of recommendations on how every person with diabetes and every healthcare professional (HCP) should be delivering insulin safely and optimally. The congress exceeded expectations through its international reach and flexible agenda to accommodate time difference needs. Sessions were very interactive and there was a great deal of enthusiasm from participants from around the world. Just over 150 specialists from 58 different countries attended the congress, with a further 4000 people from China, India, the Philippines, Indonesia, Malaysia and Latin America logging in to 32 webcasts.

The main agenda item was the sharing of results from a global injection technique study (currently awaiting publication), involving over 13 000 participants, which has informed the development of the new global injection technique recommendations. These recommendations will replace those published in 2010.

The latest recommendations include a new section on infusion, incorporating pump technology. Evidence shows that the “Achilles’ heel” of insulin infusion is the giving set. A range of issues were discussed during the congress, including silent occlusions and related interruptions in insulin flow, which can have an adverse effect on glucose control. Further review of the evidence showed that pump users are vulnerable to similar issues and complications to those who inject conventionally. These issues were found to have significant impact on health outcomes, burden and cost of care. Optimal infusion technique, coupled with state-of-the-art infusion technology, could help reduce the burden of care and help improve outcomes (Pickup et al, 2014).

It is crucial that we keep abreast of emerging research and translate it into practical information for both HCPs and people with diabetes in order to enable best practice in injection technique. Sub-optimal insulin injection delivery can contribute to poor patient outcomes, and is responsible for avoidable complications and healthcare costs. 

Evidence shows that many people who take insulin have lipohypertrophy, which is a complication of sub-optimal injection technique. Lipohypertrophy can lead to significant risk of hypoglycaemia and glycaemic variation, above-target HbA1c, poor patient satisfaction, increased insulin usage and significant burden on healthcare resources, in particular, the ambulance service, A&E and unplanned hospital admission (Grassi et al, 2014). 

This month a group of HCPs from diabetes care and people with diabetes will meet to anglicise the global recommendations to ensure they fit the way we work in the UK. Once these recommendations are agreed they will be published on the FIT website


Grassi G, Scuntero P, Trepiccioni R et al (2014) Optimizing insulin injection technique and its effect on blood glucose control. J Clin Transl Endocrinol 1: 145–50
Pickup JC, Yemane N, Brackenridge A, Pender S (2014) Nonmetabolic complications of continuous subcutaneous insulin infusion: A patient survey. Diabetes Technol Ther 16: 145–9  

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