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In the Australian D-Health RCT (n = 21,315

Key warning signs that indicate the medication should not be used include: Cloudiness or turbidity the solution should be completely clear, not milky or hazy Visible particles or precipitates any floating matter, crystals, or sediment indicates degradation Discolouration any unusual colour changes Frozen medication if the pen has been frozen, even if subsequently thawed, it must be discarded Damaged packaging cracks, leaks, or compromised seals on the pen or carton It is important to understand that not all degraded medication will show visible changes

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doi: 10.1007/s11864-019-0666-x