Skip to main content
  • More from ADA
    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • Log out
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Diabetes Care

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • Special Article Collections
    • ADA Standards of Medical Care
  • Browse
    • By Topic
    • Issue Archive
    • Saved Searches
    • Special Article Collections
    • ADA Standards of Medical Care
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
    • ADA Peer Review
  • More from ADA
    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • Log out
  • My Cart

Search

  • Advanced search
Diabetes Care
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • Special Article Collections
    • ADA Standards of Medical Care
  • Browse
    • By Topic
    • Issue Archive
    • Saved Searches
    • Special Article Collections
    • ADA Standards of Medical Care
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
    • ADA Peer Review
Letters: Observations

Regurgitation of Blood into Insulin Cartridges in the Pen-like Injectors

  1. Kazuo Sonoki, MD,
  2. Mototaka Yoshinari, MD,
  3. Masanori Iwase, MD,
  4. Kenji Tashiro, MD,
  5. Kenzo Iino, MD,
  6. Masanori Wakisaka, MD and
  7. Masatoshi Fujishima, MD
  1. Second Department of Internal Medicine, Kyushu University Hospital, Kyushu, Japan
    Diabetes Care 2001 Mar; 24(3): 603-604. https://doi.org/10.2337/diacare.24.3.603
    PreviousNext
    • Article
    • Info & Metrics
    • PDF
    Loading

    The pen-like injector for insulin is widely used by diabetic patients and improves their quality of life. However, an important disadvantage of this reusable injector is the possible contamination of biological materials (1). Macroscopic blood regurgitation into a cartridge is sometimes observed. In such a case, if the cartridges were to be used by another patient, this could result in the transmission of contagious diseases such as the hepatitis B virus. Therefore, we investigated the blood contamination in 146 cartridges used by diabetic patients by immunochromatography using anti-human hemoglobin antibody.

    Hemoglobin was detected in 6 of 146 cartridges (4.1%). The quantity of the contaminated blood per cartridge was calculated to be over 0.3 μl. We carried out a simulative examination using three types of injectors. The injector punctured a rubber tube filled with dye solution. After 800 μl of insulin (2 U insulin serially 40 times for Novopen and 4 U insulin serially 20 times for Novopen III and Autopen) was injected without changing the needle under a hydrostatic pressure of 0 cm H2O, the dye content in the cartridge was measured fluorometrically. Dye regurgitation was detected in 13 of 19 cartridges with Novopen, in 3 of 19 cartridges with Novopen III, and in only 1 of 19 cartridges with Autopen. Novopen showed the highest incidence of dye regurgitation compared with Novopen III (x2 test; P = 0.001) and Autopen (P < 0.0001). The volume of regurgitated dye solution was 0.03–0.22 μl per cartridge. When the hydrostatic pressure in the rubber tube was elevated from 0 to 5, 10, 30, and 100 cm H2O by lifting the reservoir of dye solution from a flat level to 100 cm in height, dye regurgitation occurred at each hydrostatic pressure and was independent of the hydrostatic pressure. Such regurgitation appears to be dependent on the devices used and possibly on the frequency of pressing.

    In addition, a questionnaire was administered to 193 outpatients using insulin cartridges at four outpatient clinics when collecting the patients’ used cartridges. Twenty of these patients reported noticing a reddened cartridge after insulin injection, and two patients reported sharing their insulin cartridges with other patients.

    A study on viral transmission in chimpanzees reported that, if serum was positive for hepatitis B e antigen, injection of even 10−8 dilutions of the serum (10−5 μl) in chimpanzees could result in hepatitis B virus infection (2). Our findings indicate that the amount of blood or dye regurgitated into cartridges would be sufficient to transmit hepatitis B virus infection. In fact, previous reports suggested that hepatitis B infection might be developed by dental use of pen-like injectors for local anesthesia (3,4). Of course, insulin cartridges contain anti-microbial agents (i.e., phenol or cresol) (5,6). However, these agents are effective only for killing bacteria, not viruses (7). Therefore, it is imperative that attention should be called to the careful use of cartridges as well as needles (8). Shared use of insulin cartridges must be prohibited to prevent the transmission of viral infections.

    Footnotes

    • Address correspondence to Kazuo Sonoki, MD, Department of Internal Medicine, Kyushu Dental College, Manazuru 2-6-1, Kokurakita-ku, Kitakyushu, 803-8580, Japan. E-mail: sonoki{at}mail.kyu-dent.ac.jp.

    References

    1. ↵
      Floch JPL, Lange F, Herbreteau C, Perlemuter L: Biologic material in needles and cartridges after insulin injection with a pen in diabetic patients. Diabetes Care 21:1502–1504, 1998
      OpenUrlAbstract/FREE Full Text
    2. ↵
      Shikata T, Karasawa T, Abe K, Uzawa T, Suzuki H, Oda T, Imai M, Mayumi M, Moritsugu Y: Hepatitis B e antigen and infectivity of hepatitis B virus. J Infect Dis 136:571–576, 1977
      OpenUrlAbstract/FREE Full Text
    3. ↵
      Levin M, Maddrey WC, Wands JR, Mendeloff AI: Hepatitis B transmission by dentists. JAMA 27:1139–1140, 1974
      OpenUrl
    4. ↵
      Ohkubo T, Shibata M, Haraga Y, Kaya H, Takahashi H: Blood reflux into cartridges for dental anesthesia: detection in residual solution. Clin Prevent Dent 14:17–20, 1992
    5. ↵
      Schade DS, Eaton RP: Bactericidal properties of commercial U.S.P. formulated insulin. Diabetes 31:36–39, 1982
      OpenUrlAbstract/FREE Full Text
    6. ↵
      Rathod M, Saravolatz L, Pohlod D, Whitehouse FJ, Goldman H: Evaluation of the sterility and stability of insulin from multidose vials used for prolonged periods. Infect Control 6:491–494, 1985
      OpenUrlPubMed
    7. ↵
      Scioli D, Pizzella T, Vollaro L, Nardiello S, De Feo L: The action of VIRKON No Foam on the hepatitis B virus. Eur J Epidemiol 13:879–883, 1997
      OpenUrlPubMed
    8. ↵
      World Health Organization: Expanded programme on immunization: changing needles but not the syringes: an unsafe practice. Wkly Epidem Rec 62:345–352, 1987
      OpenUrl
    PreviousNext
    Back to top
    Diabetes Care: 24 (3)

    In this Issue

    March 2001, 24(3)
    • Table of Contents
    • About the Cover
    • Index by Author
    Sign up to receive current issue alerts
    View Selected Citations (0)
    Print
    Download PDF
    Article Alerts
    Sign In to Email Alerts with your Email Address
    Email Article

    Thank you for your interest in spreading the word about Diabetes Care.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Regurgitation of Blood into Insulin Cartridges in the Pen-like Injectors
    (Your Name) has forwarded a page to you from Diabetes Care
    (Your Name) thought you would like to see this page from the Diabetes Care web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Citation Tools
    Regurgitation of Blood into Insulin Cartridges in the Pen-like Injectors
    Kazuo Sonoki, Mototaka Yoshinari, Masanori Iwase, Kenji Tashiro, Kenzo Iino, Masanori Wakisaka, Masatoshi Fujishima
    Diabetes Care Mar 2001, 24 (3) 603-604; DOI: 10.2337/diacare.24.3.603

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Add to Selected Citations
    Share

    Regurgitation of Blood into Insulin Cartridges in the Pen-like Injectors
    Kazuo Sonoki, Mototaka Yoshinari, Masanori Iwase, Kenji Tashiro, Kenzo Iino, Masanori Wakisaka, Masatoshi Fujishima
    Diabetes Care Mar 2001, 24 (3) 603-604; DOI: 10.2337/diacare.24.3.603
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    Jump to section

    • Article
      • Footnotes
      • References
    • Info & Metrics
    • PDF

    Related Articles

    Cited By...

    More in this TOC Section

    • Weight Gain and Gestational Diabetes Mellitus Is a Sensitive Issue
    • Beneficial Effects of a 4-Week Exercise Program on Plasma Concentrations of Adhesion Molecules
    • Malignant Melanoma Misdiagnosed as a Diabetic Foot Ulcer
    Show more Letters: Observations

    Similar Articles

    Navigate

    • Current Issue
    • Standards of Care Guidelines
    • Online Ahead of Print
    • Archives
    • Submit
    • Subscribe
    • Email Alerts
    • RSS Feeds

    More Information

    • About the Journal
    • Instructions for Authors
    • Journal Policies
    • Reprints and Permissions
    • Advertising
    • Privacy Policy: ADA Journals
    • Copyright Notice/Public Access Policy
    • Contact Us

    Other ADA Resources

    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • Scientific Sessions Abstracts
    • Standards of Medical Care in Diabetes
    • BMJ Open - Diabetes Research & Care
    • Professional Books
    • Diabetes Forecast

     

    • DiabetesJournals.org
    • Diabetes Core Update
    • ADA's DiabetesPro
    • ADA Member Directory
    • Diabetes.org

    © 2021 by the American Diabetes Association. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548.