Knowledge regarding hypoglycemia and insulin
Hypoglycemia is one of the most common acute complications of diabetes mellitus. The knowledge of patients associated with hypoglycemia will help in the prevention and management of the problem.  The study revealed that that the majority of patients were familiar with symptoms and remedial measures for hypoglycemia, but much fewer patients knew the level of glycaemia considered as hypoglycemia, precipitating factors of hypoglycemia or using glucometer to check blood glucose at home. The poor knowledge maybe is reasons why the rate of hypoglycemia during previous month of patients was quite high (57.5%). This hypothesis was confirmed by statistical analysis when patients having good knowledge were less likely to get hypoglycemic (p=0.001) (Table 5). These findings are consistent with the prior study in India19. They found that only 66.1% diabetic patients had good knowledge on hypoglycemia. Other study of Kahsay et al. found that self/family blood glucose monitoring at home could not guarantee to minimize the occurrence of hypoglycemia events20.
Regarding the knowledge of the insulin pen use, the majority of the patients knew various types of insulin, injection sites, requirement of rotation of the injection sites, injection site complications, and the right time to inject insulin regard to meals, and storage condition of spare insulin pens. However, the survey revealed that many patients did not have good knowledge on insulin needle and expiration date after opening the pen. For example, only 9 patients (6.1%) knew to have to use a new pen needle for each injection while the others (93.9%) reused needles many times for savings. If the needle is not removed from the pen between two injections, air may leak into the injector causing wrong dose insulin injection10. Reusing the needle may result in distortion, bending of needle encountered in 7 patients and can cause painful injections in 60.1%. Other studies reported that pen needle reuse was quite high in their study with a range of 50%-80%9,10and this problem increased the risk of lipohypertrophy7,8,10. Compared to other studies, this very disappointing result in our study requires special attention on this point at patient education.
Many patients misunderstood that the in-use insulin pens had to be kept in the refrigerator at 2-80C. Mitchell et al.9 reported that three-fourths of users did not follow the manufacturer’s instructions for storage of the in-use insulin pens. All patients knew the location of abdominal injection, but only 62.8% of patients knew more than one injection site on the body. A survey in China reported that more than 80% of patients only limited changes in the abdominal area8. The repetition of the same injection site increased the risk of lipohypertrophy7. In our study, 14.9% patients reported lipodystrophy while this rate was 29.0% in other study7.