The Centers for Disease Control and Prevention (CDC) is warning diabetics and caregivers that insulin pens must never be used on more than one person.

Agency officials say they have become increasingly aware of reports of improper use of insulin pens, which places individuals at risk of infection including hepatitis viruses and human immunodeficiency virus (HIV).

Regurgitation of blood into the insulin cartridge can occur after injection creating a risk of bloodborne pathogen transmission if the pen is used for more than one person, even when the needle is changed.

The pen-shaped injector devices contain a reservoir for insulin or an insulin cartridge. These devices are designed to be used multiple times, for a single person, using a new needle for each injection. Insulin pens must never be used for more than one person.

The recent warning follows an alert issued in 2009. The Food and Drug Administration (FDA) issued an alert for healthcare professionals reminding them that insulin pens are meant for use on a single patient only and are not to be shared between patients. In spite of this alert, there have been continuing reports of patients placed at risk through inappropriate reuse and sharing of insulin pens, including an incident in 2011 that required notification of more than 2,000 potentially exposed patients. These events indicate that some healthcare personnel do not adhere to safe practices and may be unaware of the risks these unsafe practices pose to patients.

Recommendations

Insulin pens should be clearly labeled with the person’s name or other identifying information to ensure that the correct pen is used only on the correct individual.

Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices.

If reuse is identified, exposed persons should be promptly notified and offered appropriate follow-up including bloodborne pathogen testing.

These recommendations apply to any setting where insulin pens are used, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps as well as licensed healthcare facilities.