Abstract
True or false? Insulin must be kept refrigerated or on ice.
You may know the answer. But do your patients know?
The need to refrigerate all insulin has become a popular misconception. US insulin manufacturers state in both prescriber and patient information that unopened insulin should be stored in the refrigerator; however, they specify that pens in use are to be kept at room temperature and that insulin vials in use may be kept refrigerated or at room temperature.
The belief that all insulin must be kept refrigerated may affect people with diabetes in several ways:
■ It can be a significant barrier to taking insulin regularly if people opt to—or feel they have to— miss a dose because there is no convenient way to keep insulin with them.
■ It can interfere with plans for outings and events, causing some people to stay home to take their insulin and let treasured opportunities go by.
■ It can prevent the pursuit of life experiences and interests when the need for refrigerated insulin seems to make them impossible.
Here are a few stories that illustrate how strongly some people with diabetes hold on to their beliefs about insulin storage and how it affects their lives and self-management.
Alice
Alice lives in a small house with her 2 daughters and 4 grandchildren. To take her bedtime insulin injection, she has to cross the living room where they are all watching TV.
“I don’t take my insulin every night. Sometimes I forget,” Alice says to me.
“Where do you keep your insulin?” I ask.
“In the fridge,” she replies.
Alice gets her insulin vial from the kitchen, takes it to her bedroom, injects her insulin dose, returns the vial to the kitchen, and goes back to her bedroom to retire for the night. She doesn’t wait for the insulin to warm up, so her injections are often painful.
US insulin manufacturers state in both prescriber and patient information that unopened insulin should be stored in the refrigerator, however, they specify that pens in use are to be kept at room temperature and insulin vials in use may be kept refrigerated or at room temperature.
“What if you kept your insulin vial in the drawer beside your bed?” I ask. Alice is not convinced.
Marcus
Marcus and his brother both have diabetes. Marcus takes long-acting insulin and his brother takes long-acting and rapid-acting insulin. They keep their insulin on the same shelf in the refrigerator. Marcus grabbed the wrong vial recently, took 20 units of rapid-acting insulin by mistake, and went to bed. Hypoglycemia had him thrashing and mumbling.
“My brother knew what to do,” he shrugged. “He woke me up and gave me juice.”
Uncle Al
My dad was 80, lived alone, and ate breakfast in a neighborhood cafe where he could socialize. “Uncle Al,” friends called out and came to sit with him. That happy arrangement crashed when my dad’s doctor prescribed premeal insulin. He stopped going out for breakfast.
“But dad, you can put your insulin pen in your shirt pocket and take it with you,” I urged.
“No, I can’t, it would be out of the refrigerator too long,” he insisted.
My Own Story
After college, I moved to a small Western town where the mountains were moments away. With my first paycheck, I bought a tarp, a sleeping bag, and a camping stove. I worked Monday through Friday, and on Friday afternoons, I drove into the mountains to camp. I carried a small cooler that held ice and my insulin. Instead of worrying about bears, I worried about my insulin. Would it freeze overnight? What if the ice melted when I left the little cooler under the tarp or in my car?
When I suggested Marcus could keep his insulin in his room to avoid making that mistake again, he shook his head. He was sure the insulin should be refrigerated.
My campout weekends were troubled. Then a doctor on a Navajo reservation—where many families did not have electricity—told me my insulin vial didn’t have to be refrigerated or on ice.
Freed, I took a wilderness training course, became a backpacker, and hiked for days with my insulin wrapped in a sweater and buried in my pack. At night I kept it in my sleeping bag with me so it wouldn’t freeze.
Keeping insulin out of direct light, above freezing, and below 86°F is workable. Even in extreme temperatures, there are options. Numerous insulated cases and kits are available. I now keep my insulin in a small cloth bag with a pull-out lining that absorbs water. It stays cool and dark and goes everywhere with me.
“Cool and dark,” is my insulin mantra.
“Cool and dark,” is my insulin mantra.
WHAT DIABETES EDUCATORS CAN DO
→ Communicate that proper insulin storage is vital.
→ Assure people with diabetes that they may keep insulin pens or vials in use with them or anywhere that’s cool and dark.
→ Confirm that it’s not necessary to keep opened insulin cold but that it does need to be protected from direct heat and light.
→ Point out storage guidelines on the information sheet inserted in insulin boxes.
→ Explain that the body responds better to insulin taken at room temperature and that injections are less likely to hurt.
→ Brainstorm ways to store insulin conveniently and effectively with each individual.
→ Help identify and break down barriers to following their insulin plan as prescribed.
Footnotes
Karen Meadows, MA, MS, CDE, is in private practice in Santa Fe, NM.