Medication management—whether it involves taking aspirin for a headache, managing multiple pill regimens, or measuring insulin—is one of the earliest obstacles that people with vision loss must confront in order to continue living independently. Most people are able to address these issues by adopting a few new skills.
For information on Managing Your Medications, visit the Know Your Meds section. Here you will find useful information about organizing and identifying your medications. Another helpful section is Guidelines for Prescription Labeling. Share these guidelines for labeling of prescription and over-the-counter medications with your pharmacist. Also, AFB has completed a nationwide Access to Drug Labels Survey of issues that persons with vision loss are experiencing with accessing medication labeling.
Management of Insulin is another challenging area of diabetes control. While insulin treatments certainly present more than the usual challenges, these skills can be mastered with the right tools, time, and care. Your diabetes educator should be your primary resource for information, but here are a few tips:
Drawing Insulin with Vial and Syringe
The use of syringe magnifiers or tactile measurement devices can make it a simple matter to measure a correct dose of insulin using a vial and syringe, even if you have severe vision loss. If you go with either of these methods, you will need to know how to get rid of air bubbles in the syringe. Although not a danger if injected, air bubbles left in the syringe mean that you will have missed part of your dose of insulin. Since you won't be able to see these bubbles, you will need a reliable way to make sure that they've been pushed out of the syringe. Follow these steps:
- Fill the syringe with the amount of air that equals your dose of insulin.
- Inject the air into the insulin bottle.
- Turn the syringe and bottle so that the bottle is on top, facing down. With most of the measurement devices, this is easy because the devices hold the syringe and bottle together.
- Pull the plunger out, and push it back in three times. The first time you do this, you will probably hear air bubbles going into the insulin bottle. By the third time, you will not hear any more air bubbles.
- Draw your dose of insulin.
If you are using a device to mix two types of insulin:
- Draw and inject air into your longer-acting insulin first, but do not draw any insulin.
- Inject air into your shorter-acting insulin, and go through the procedure above.
- Finally, simply draw the longer-acting insulin. Do not push any insulin back into the bottle.
When to Throw Out an Insulin Vial
If you are drawing insulin from a vial, you need to know when it's time to throw it out. Every vial of insulin contains 1,000 units and has a shelf life of about four weeks, so if you use less than 1,000 units per month, it's a good rule of thumb to replace your insulin vial once a month. If you use more than one vial per month, it's important to replace the bottle before all the insulin runs out. If the level of insulin dips below 50 units, it becomes easier to draw air into the syringe without being aware of it. If you are unable to assess the amount remaining visually, you can work it out mathematically.
Remember, every bottle of insulin has 1,000 units, and you want to replace it before you draw the last 50 units. To figure out how many days you can use a bottle of insulin:
- Subtract 50 from the total amount; you will use 950 units from a new vial.
- Divide 950 units by your daily dose. For example, if you use 50 total units of insulin every day (either in one dose, or in two or more doses added together), that's 950 divided by 50, which comes to 19 days worth of insulin per vial.
- If the dose does not divide exactly into 950, leave more, rather than less, insulin in the vial. For example, if you take 48 units of insulin per day, you would still use the vial of insulin for 19 days.
Here's an easy way to keep track of when to change your vial of insulin:
- If you take insulin once a day, count out the number of syringes you would use to leave at least 50 units in the bottle. In the example above, if you take all 50 units in one dose, you would count out 19 syringes.
- If you take insulin more than once a day, multiply the number of days by the doses in one day. In the example above, if you take 25 units per dose, and you take insulin twice a day, multiply 19 days by two doses, and you need 38 syringes.
- Set aside the number of syringes you have counted out. Put them in a box, cup, drawer, or other container. When you have used them up, it's time to start a new vial.
Devices for Taking Your Insulin
There are several types of syringe magnifiers that can work well for people who have reliable low vision. However, if your vision fluctuates or is changing, be cautious! These magnifiers provide only about 2X magnification. Many people who have a visual impairment with diabetes find that their vision is at its worst when their blood glucose is high. This is a time when you need to be able to measure insulin accurately, so if you choose a magnifier, be sure you can use it even when your vision is at its worst. If you have any doubts, go for a tactile measurement device instead. Again, there are several kinds of tactile devices on the market, many of which can be used independently by people with vision loss. Check out AFB's Product Guide for more information.
The following devices give users the ability to get an accurate non-visual measurement of insulin using standard disposable syringes:
- Inject-Aid holds an insulin bottle and syringe in alignment so that the needle of the syringe is easy to insert correctly. It can be used with any size or brand of syringe. A drawback for people with vision loss is that they would need a sighted person to preset the device to one dose of insulin. You cannot set it for a different dose independently.
- The Safe Shot Syringe Holder is available in both red and yellow versions to make it easier to distinguish two different doses of insulin. It holds an insulin bottle and syringe in alignment, so the needle of the syringe is easy to insert correctly, and can be used with any size or brand of syringe. Like Inject Aid, the dosage must be preset by a sighted person.
- Syringe Support holds an insulin bottle and syringe in alignment, so the needle of the syringe is easy to insert correctly. If you are visually impaired, you can independently set any desired dosage by turning a calibration screw. The device can also be used to mix types of insulin. It is accurate only when used with a BD 100-unit syringe.
- Count-a-Dose is available through Diagnostic Devices, Inc., at the following website: Prodigy Meters. It is used with a BD 50-unit syringe, and can hold either one or two different bottles of insulin. If you have a Count-a-Dose, to measure insulin, turn the click-wheel with the thumb of your right hand. You will be able to hear and feel a click of the wheel for each unit of insulin. Insulin can be measured in any dose in one-unit increments. This device has been purchased by a new manufacturer and should be back on the market sometime late in 2010.
The Pen is Mightier. . .
An insulin pen looks identical to a large pen, but is filled with insulin rather than ink. Some pens can be refilled with cartridges that you load into the device, and others come pre-filled with insulin. Most people find pre-filled pens to be the simpler option, since there are fewer steps for their use.
For all insulin pens, you set the dose by turning a knob at the end of the pen, producing a click that you can hear and feel for each unit of insulin. To give yourself an injection using a pen, you use a disposable needle that you screw onto the end of the pen. After the injection is finished, you remove the needle.
Most insulin pens sold in the United States contain a disclaimer stating that they are not made for use by people with visual impairments. Although these devices have not been designed to be fully accessible, they can be used safely and independently with training and practice. All over the world, people with visual impairments successfully use the pens to measure and administer their insulin independently. However, it is recommended that people with visual impairments receive instruction in insulin pen use from a diabetes educator, who can check their techniques for accuracy.
How will I know when my pen is running low on insulin?
The answer differs depending on which type of pen you use. A pre-filled pen that is nearly empty simply will not dial a dose that is greater than the amount remaining. On the other hand, some refillable devices will dial a larger dose than the amount of insulin remaining, which means you will need to keep close track of your insulin supply to avoid administering a smaller dose than you need.
All pen cartridges currently on the market contain 300 units of insulin. You can calculate how long one cartridge will last for you in the same way that you can calculate how long to use an insulin vial, as described above. (But you do not need to subtract 50 units, since you don't need to leave any insulin remaining in the pen cartridge.) Similarly, you can keep track of how long to use a cartridge by counting out pen needles instead of syringes, as described above.
The Air Shot and Vision Loss
One procedure that people need to adapt for all insulin pens and similar devices is the air shot. This involves delivering a small amount of insulin with the pen pointed up into the air. This is to exhaust any air bubbles that might have collected in the cartridge, and to ensure that the system is functioning properly. When a small amount of insulin has been delivered, it usually drips down the side of the needle. By tapping the plastic rim of the disposable needle on the back of your hand or the inside of your arm, the drops fall on the skin. If the drops are too small to feel, you can spread the drops with the fingers of the opposite hand, blow on them and feel the coolness. Alternatively, many people can smell the distinctive odor of insulin.
For More Information:
- AccessWorld® Diabetes and Visual Impairment: Are Insulin Pens Accessible? An overview of different insulin pens, insulin pen use and safety, and top recommendations for pens for people with vision loss.
- Eli Lilly Insulin Pens. Follow the link to "Insulin Pens."
- NovoNordisk Insulin Pens
- Owen Mumford Insulin Pens
- Sanofi-Aventis Insulin Pens
- Sanofi Aventis Insulin Pens Additional Link
- Sanofi Aventis Insulin Pens Additional Link
Adapting the Insulin Pump
How the Pump Works
An insulin pump is a small electronic device—about the size of a pager or cell phone—used to deliver insulin. Most pump systems consist of the pump itself, a tube to carry the insulin from the pump to the body, and an insertion set—a needle or small bit of tubing placed just under skin to bring the insulin into the body.
Generally, only rapid-acting insulin is used in a pump. It is delivered to the body two ways:
- as a basal dose, a small amount delivered continuously to keep the blood glucose steady between meals; and
- as a bolus dose, an amount of insulin given with a meal, calculated to allow the body to absorb carbohydrates and to correct any high blood glucose. This method closely mimics how the pancreas works for people who do not have diabetes.
Challenges and Benefits
Proper use of an insulin pump requires extensive instruction from a diabetes educator specifically trained for the task. It also requires close medical follow-up with a doctor, usually an endocrinologist. For those able to manage the pump successfully, the benefits are considerable. You can fine-tune insulin delivery in ways that are not possible with injected insulin. This, in turn, can help you maintain blood glucose levels that are very close to normal, often with less hypoglycemia (low blood sugar) than is possible with injected insulin.
While pumps are not commonly used by people with vision impairment, each of the insulin pump systems currently on the market is being used by someone, somewhere, with vision loss. Even some insulin users with total blindness find ways to manage with a pump, though with considerable effort. Insulin pumps have not been designed for non-visual accessibility.
Most of the current pumps use successive screens with visual menus to perform such routine procedures as setting the basal and bolus doses and accessing the pump memory. If you have minimal vision loss, a pump that has a backlighting feature and a pump screen magnifier may help to make the screens at least partially accessible. In general, pump users with severe visual impairment are able to access only some of the insulin pump capabilities.
To Find Out if a Pump Can Work for You. . .
You will need to consult with a doctor who prescribes insulin pumps regularly. Generally, this will be an endocrinologist, although a few other doctors also work with pumps. Because there are so few visually impaired insulin pump users, your endocrinologist may have never worked with one. Be persistent. A diabetes educator who works with insulin pumps, or pump trainers from the pump companies can help you decide whether an insulin pump could work for you.
For More Information:
- National Federation of the Blind. Many Blind Diabetics Successfully Use Insulin Pumps.
- Diabetes Mall. Diabetes Technology: Comparison of Current Pumps.
- American Diabetes Association. 2008 Resource Guide.
- AccessWorld. Are Insulin Pumps Accessible?