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Domingo-Lopez DA, Lattanzi G, H. J. Schreiber L, Wallace EJ, Wylie R, O'Sullivan J, Dolan EB, Duffy GP. Medical devices, smart drug delivery, wearables and technology for the treatment of Diabetes Mellitus. Adv Drug Deliv Rev 2022; 185:114280. [PMID: 35405298 DOI: 10.1016/j.addr.2022.114280] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/21/2022] [Accepted: 04/05/2022] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus refers to a group of metabolic disorders which affect how the body uses glucose impacting approximately 9% of the population worldwide. This review covers the most recent technological advances envisioned to control and/or reverse Type 1 diabetes mellitus (T1DM), many of which will also prove effective in treating the other forms of diabetes mellitus. Current standard therapy for T1DM involves multiple daily glucose measurements and insulin injections. Advances in glucose monitors, hormone delivery systems, and control algorithms generate more autonomous and personalised treatments through hybrid and fully automated closed-loop systems, which significantly reduce hypo- and hyperglycaemic episodes and their subsequent complications. Bi-hormonal systems that co-deliver glucagon or amylin with insulin aim to reduce hypoglycaemic events or increase time spent in target glycaemic range, respectively. Stimuli responsive materials for the controlled delivery of insulin or glucagon are a promising alternative to glucose monitors and insulin pumps. By their self-regulated mechanism, these "smart" drugs modulate their potency, pharmacokinetics and dosing depending on patients' glucose levels. Islet transplantation is a potential cure for T1DM as it restores endogenous insulin and glucagon production, but its use is not yet widespread due to limited islet sources and risks of chronic immunosuppression. New encapsulation strategies that promote angiogenesis and oxygen delivery while protecting islets from recipients' immune response may overcome current limiting factors.
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Pasquarella M, Romano C, Alfrone C, Giordano L, Loiacono F, Capece M, Lamberti R, Strollo F. The Economic Burden of Insulin Injection-Induced Lipohypertophy. Role of Education: The ISTERP-3 Study. Adv Ther 2022; 39:2192-2207. [PMID: 35306633 PMCID: PMC9056437 DOI: 10.1007/s12325-022-02105-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
Abstract
Introduction The history of insulin-induced skin lipohypertrophy (LH) runs parallel to that of insulin's 100 years, and an average of 47% of insulin-treated patients still suffer from it today. The metabolic and economic effects of LH are significant, with hypoglycemia being the most striking. The objective of the study was to perform a 52-week follow-up of 713 insulin-treated patients with type 2 diabetes (T2DM) and LH to detect any differences in the occurrence of hypoglycemic events (HYPOs) and related healthcare costs as well as in LH rates and injection habits between an intensive education intervention group (IG) and control group (CG) provided with a single educational session at the starting point. Methods All participants were trained in accurately self-monitoring blood glucose and recording all HYPOs for 6 months, which allowed baseline recordings before they were randomized into the IG, comprising 395 insulin-treated subjects undergoing repeated, structured multimodal education on correct injection techniques as a longstanding behavioral rehabilitation strategy, and the CG, comprising 318 subjects receiving the same structured, multimodal educational session, but only initially. Results Changes in LH rate and size and in performance were large in the IG and only slight and transient in the CG. A striking difference in the rate of decrease of HYPOs was also apparent between groups. Indeed, estimated costs of health interventions for severe and symptomatic HYPOs, which were on the order of €70,000 and €9300, respectively, in the two groups at baseline decreased by 5.9 times and 13.7 times, respectively, at the end of follow-up in the IG and by only approximately half in the CG. Full details of the changes occurring as a result of intensive education are provided in the text. Conclusions The effect of only initial education in the CG was not significant, thus providing evidence of the virtual worthlessness of a single training session on injection techniques, typical of worldwide daily clinical practice, and easily explaining the extremely high prevalence of LH in insulin-treated patients. Conversely, highly positive effects on LH prevalence and size as well as costs expected from decreased HYPO rate were obtained in the IG. To our knowledge, ours is the first 18-month randomized trial in the field. If our experimental model were to be used as an effective, longstanding behavioral rehabilitation strategy and therefore adapted to real-world settings universally, LH prevalence and costs related to their clinical consequences would be drastically reduced. However, only with a strong, relentless commitment of universities, scientific societies, and patient associations can we achieve this ambitious goal, which would provide great institutional savings and improved quality of life for people with diabetes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02105-5.
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Affiliation(s)
- Sandro Gentile
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Giuseppina Guarino
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Teresa Della Corte
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Polyspecialistic Nephrologic Center CNP Srl, Fratta Maggiore, Italy
| | | | | | | | - Laura Giordano
- Emodialysis Center Srl, Nefrocenter Network, Naples, Italy
| | | | - Maurizio Capece
- Vomero Center Crisci Bersabea & C SNC, Nefrocenter Network, Naples, Italy
| | | | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
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Hashem R, Mulnier H, Abu Ghazaleh H, Halson-Brown S, Duaso M, Rogers R, Karalliedde J, Forbes A. Characteristics and morphology of lipohypertrophic lesions in adults with type 1 diabetes with ultrasound screening: an exploratory observational study. BMJ Open Diabetes Res Care 2021; 9:9/2/e002553. [PMID: 34876413 PMCID: PMC8655520 DOI: 10.1136/bmjdrc-2021-002553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/14/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Lipohypertrophy is a common complication of exposure to insulin therapy. Despite the prevalence of lipohypertrophy and its potentially hazardous effects on glucose regulation, it remains a relatively understudied problem in diabetes. The objective of this study was to characterize lipohypertrophic tissue using ultrasound in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS An observational study of 74 people with type 1 diabetes from a diabetes center in South East London. Participants' insulin exposed areas were scanned with ultrasound, with a high-frequency linear probe (6-13 MHz). The observed tissue changes were described, measured and graded according to nodule size and thickness of the dermal layer. RESULTS Participants mean age and diabetes duration were 40.6 (±14.2) and 18.3 (±10.9) years, respectively, and 60% (n=44) were male. A total of 740 lipohypertrophic nodules were observed, ranging from 1.8 mm to 40 mm in width. The mean (SD/range) number of nodules per participants was 10.4 (±6.2/1-29). Delineation between the dermal layers was disrupted in all current injection sites. In 52 participants (70%), there was a 30% increase in dermal thickness compared with local none injected tissue, and in 36 participants (48%) the increase was 50%. The level of thickness was >3 mm in the abdominal areas of 22 (40%) of these participants and in thighs of eight participants (17.8%). Hypoechogenic areas suggestive of necrotic tissue were observed within the lipohypertrophic nodules of 22 (30%) participants. Needle length and nodule depth were correlated (r=0.69, p<0.001). A conceptual model of the insulin exposed tissue changes observed was constructed. CONCLUSIONS The study confirms that insulin-exposed tissue changes are heterogenous and has provided conceptual and grading frameworks for classifying these changes. Further studies are required to establish the clinical implications of these classifications, in relation to glucose regulation and other clinical parameters.
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Affiliation(s)
- Rabab Hashem
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Henrietta Mulnier
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Haya Abu Ghazaleh
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Susan Halson-Brown
- Department of Women & Children's Health, King's College London, London, UK
| | - Maria Duaso
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Rebecca Rogers
- Division of Care in Long-term Conditions, King's College London, London, UK
| | | | - Angus Forbes
- Division of Care in Long-term Conditions, King's College London, London, UK
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Arora S, Agrawal NK, Shanthaiah DM, Verma A, Singh S, Patne SCU, Kalra S, Singh P, Goyal S. Early detection of cutaneous complications of insulin therapy in type 1 and type 2 diabetes mellitus. Prim Care Diabetes 2021; 15:859-864. [PMID: 34154931 DOI: 10.1016/j.pcd.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/01/2021] [Accepted: 06/12/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Subcutaneous insulin therapy is associated with important injection site complications, which can influence insulin pharmacokinetics resulting in glycemic fluctuations above and below target levels for blood glucose. OBJECTIVE Our objective was to assess the prevalence and risk factors of cutaneous complications including insulin derived amyloidosis in insulin-injecting diabetes patients and to study the role of ultrasonography (in comparison to gel-assisted palpation) in early diagnosis of lipohypertrophy (LH). METHODS This was a cross-sectional study conducted at a tertiary care center in India, wherein 500 patients injecting insulin for ≥2 years were randomly enrolled and evaluated for the presence of cutaneous complications of insulin therapy through clinical examination, ultrasonography and punch biopsy of skin. RESULTS Clinical examination detected LH in 44.6% of patients. Ultrasonography diagnosed additional 13.4% of patients with LH which were missed on clinical examination. Incorrect rotation of sites (P < 0.001) and insulin syringe reusage for more than five times (P < 0.001) significantly increased the risk of LH. Skin biopsy was performed in 100 cases, out of which two patients showed apple green birefringence and its association with insulin was confirmed by positive staining with anti insulin antibody in these two patients. CONCLUSION Improper rotation of sites and reuse of needles were the leading causes of LH in Indian diabetic patients. Ultrasonography is more objective and reliable method of detecting LH. Insulin-derived amyloidosis may be a more common complication of insulin therapy than previously thought.
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Affiliation(s)
- Saurabh Arora
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Neeraj Kumar Agrawal
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Dhananjaya Melkunte Shanthaiah
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Ashish Verma
- Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Sanjay Singh
- Department of Dermatology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Shashikant C U Patne
- Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India.
| | - Parminder Singh
- Department of Endocrinology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
| | - Saloni Goyal
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
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Wang K, Zhang S, Liu C, Chen Y. A meta-analysis and meta-regression on the prevalence of lipohypertrophy in diabetic patients on insulin therapy. Therapie 2021; 76:617-628. [PMID: 33958198 DOI: 10.1016/j.therap.2021.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/14/2021] [Accepted: 04/06/2021] [Indexed: 12/16/2022]
Abstract
AIMS OF THE STUDY This study aimed to assess the prevalence of lipohypertrophy (LH) in diabetes mellitus (DM) patients on insulin therapy and identify factors influencing the prevalence rates through a meta-analysis and meta-regression. METHODS Databases of PubMed, Embase, Scopus, and Google Scholar were screened from inception to 20th Aug 2020. Data on prevalence was transformed using the logit transformation for pooling the proportions using the DerSimonian-Laird meta-analysis model. Random-effects meta-regression analysis was performed to assess the influence of the following moderators on the pooled prevalence: male gender, mean age, type of DM, DM duration, duration of insulin therapy, needle re-users, rotation of injection site, HbA1c, insulin dose, ≥8mm needle users and mean number of injections/day. RESULTS Forty-five studies were included. LH was diagnosed by observation and palpation by all studies. On meta-analysis of data from 26,865 participants, the overall prevalence of LH was found to be 41.8% (95% CI: 35.9% to 47.6%). On region-wise analysis, pooled prevalence of LH in Europe was 44.6% (95% CI: 37.5% to 51.8%) in Africa was 34.8% (95% CI: 16.9% to 52.8%) and in Asia was 41.3% (95% CI: 27.2% to 55.3%). The pooled prevalence of LH in studies only on type 1 and type 2 DM patients was 39.9% (95% CI: 28.3% to 51.6%) and 45.9% (95% CI: 29.5% to 62.4%) respectively. Only insulin duration was found to significantly influence the prevalence of LH on meta-regression. CONCLUSION Our study indicates that the prevalence of LH in DM patients on insulin therapy is estimated to be 41.8%. The longer the duration of insulin therapy, the higher is the prevalence of LH.
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Affiliation(s)
- Ke Wang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China; Yancheng First Hospital, Affiliated Hospital of Nanjing University Medical School, The First People's Hospital of Yancheng, 210028 Nanjing, Jiangsu, P.R. China
| | - Shaohong Zhang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China
| | - Chao Liu
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China.
| | - Yan Chen
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 210028 Nanjing, Jiangsu, P.R. China; Jiangsu Province Academy of Traditional Chinese Medicine, 210029 Nanjing, Jiangsu, P.R. China
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Kamrul-Hasan A, Paul AK, Amin MN, Gaffar MAJ, Asaduzzaman M, Saifuddin M, Mustari M, Alam MJ, Shahid MM, Nahid-Ul-Haque KM, Alam MS, Rahman MM, Talukder SK, Kader MA, Akter F, Hannan MA, Chanda PK, Bakar MA, Selim S. Insulin Injection Practice and Injection Complications - Results from the Bangladesh Insulin Injection Technique Survey. EUROPEAN ENDOCRINOLOGY 2020; 16:41-48. [PMID: 32595768 DOI: 10.17925/ee.2020.16.1.41] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/08/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Diabetes mellitus is highly prevalent in Bangladesh and insulin is often needed for diabetes control. We lack sufficient data on the insulin injection technique and injection-related complications. METHODS The Bangladesh Insulin Injection Technique Survey (BIITS) was conducted in 2018 in 18 centres throughout Bangladesh, involving 847 patients taking insulin for at least 6 months. All of the study subjects were interviewed using a structured questionnaire focusing on key insulin injection parameters. RESULTS The mean duration of insulin use by the study subjects was 3.84 (± 4.05) years and the mean daily dose of insulin was 41 (± 25) units. A total of 71.6% participants performed ≤2 injections/day and premixed insulins were the most commonly used insulins. Mean glycated haemoglobin (HbA1c) was 9.5% (± 2%). The proportion of syringe users and pen-device users was 68.1% and 31.9%, respectively. Most of the participants injected in the abdomen and rotated the injection site(s). The majority lifted the skinfold correctly and inserted the needle at a 90-degree angle, but their dwell times after injections were not adequate. A total of 9.2% of the subjects had injection-site lipohypertrophy (LH) and among them, 38.5% injected into the lesion. Patients with LH had higher HbA1c. Higher duration of insulin use (≥5 years), reusing needles more often (>10 times), and injecting at angles other than 90 degrees were independent predictors of LH. The incidences of hypoglycaemia (36.7%) and hyperglycaemia (67.4%) were very high, and subjects with LH had higher chances of both hypoglycaemia and hyperglycaemia. Though most (92.1%) of the patients received education about insulin injection initially, it was not repeated in the recent follow-up and was found to be ineffective. CONCLUSION A huge gap between the insulin administration guidelines and current practice was observed in this study. Complications of insulin injections were also common. Healthcare providers should pay more attention to insulin education and re-evaluate injection practices from time to time.
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Affiliation(s)
- Abm Kamrul-Hasan
- Department of Endocrinology, Mymensingh Medical College, Mymensingh, Bangladesh
| | - Ajit Kumar Paul
- Department of Endocrinology, Mainamoti Medical College, Cumilla, Bangladesh
| | | | - Md Abu Jar Gaffar
- Department of Physiology, Naogaon Medical College, Naogaon, Bangladesh
| | - Md Asaduzzaman
- Department of Endocrinology, Shaheed Sheikh Abu Naser Specialized Hospital, Khulna, Bangladesh
| | | | - Marufa Mustari
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md Jahangir Alam
- Department of Endocrinology, Shaheed Ziaur Rahman Medical College, Bogura, Bangladesh
| | | | - K M Nahid-Ul-Haque
- Department of Endocrinology, Diabetic Association Medical College, Faridpur, Bangladesh
| | | | - Md Motiur Rahman
- Department of Medicine, Rajshahi Medical College Hospital, Rajshahi, Bangladesh
| | | | - Md Abdul Kader
- Department of Endocrinology, Diabetic Association Medical College, Faridpur, Bangladesh
| | - Farhana Akter
- Department of Endocrinology, Chittagong Medical College, Chittagong, Bangladesh
| | | | - Palash Kumar Chanda
- Department of Endocrinology, Mymensingh Medical College, Mymensingh, Bangladesh
| | - Muhammed Abu Bakar
- Department of Endocrinology, Chattogram Maa-Shishu O General Hospital, Chittagong, Bangladesh
| | - Shahjada Selim
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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Gentile S, Strollo F, Satta E, Della-Corte T, Romano C, Guarino G. Insulin-induced lypodistrophy in hemodialyzed patients: A new challenge for nephrologists? Diabetes Metab Syndr 2019; 13:3081-3084. [PMID: 31765982 DOI: 10.1016/j.dsx.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Diabetes Mellitus (DM) is the most common cause of renal failure and ESRD all over the world, and often requires an individualized insulin treatment regimen. Malnutrition, depression-related eating behavior changes, high on-off-dialysis day-to-day glycemic variability and frequent hypoglycemic events occurring during or immediately after dialysis make it hard to identify best insulin dosage in hemodialyzed patients. This suggests a prudent attitude including non-stringent control, despite which repeated hypoglycemia quite often occurs in such patients. When looking for possible sources of hypoglycemia, health professionals too often overlook the identification of skin lipodystrophy (LD) due to an incorrect insulin injection technique. This mini-review focuses on the high frequency (57%) of LD in a cohort of 1004 insulin-treated people with DM on dialysis consecutively referring to our joint medical centers, and on its relationship with hypoglycemia and glycemic control/variability. When taking on such patients, care team members accept to face a complex disease burdened with several risk factors requiring high professional skills, and have to keep in mind also the possible presence of any LD areas eventually interfering with expected results. A timely educational intervention on the correct injection technique can help reduce the high risk of hypoglycemia and large glycemic variability in dialysed people with DM.
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Affiliation(s)
- S Gentile
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy.
| | - F Strollo
- Nefrocenter Research Network, Naples, Italy; Elle-Di and San Raffaele Research Institute, Rome, Italy
| | - E Satta
- Nefrocenter Research Network, Naples, Italy
| | - T Della-Corte
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy
| | - C Romano
- Nefrocenter Research Network, Naples, Italy
| | - G Guarino
- Campania University ''Luigi Vanvitelli", Naples, Italy
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Hirsch LJ, Strauss KW. The Injection Technique Factor: What You Don't Know or Teach Can Make a Difference. Clin Diabetes 2019; 37:227-233. [PMID: 31371853 PMCID: PMC6640874 DOI: 10.2337/cd18-0076] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IN BRIEF To be consistently effective, insulin must be delivered into subcutaneous tissue. If insulin is delivered intramuscularly, its uptake and action become variably faster, leading to suboptimal, inconsistent glucose control. The best strategy to avoid intramuscular injection is to use the shortest needles available. Injection sites should be rotated systematically to prevent lipohypertrophy, which also substantially affects insulin uptake and action. New evidence-based insulin delivery recommendations are available, and awareness of them should lead to more effective use of insulin therapy, improved clinical outcomes, and considerable cost savings.
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Song Z, Guo X, Ji L, Huang X, Hirsch LJ, Strauss KW. Insulin Injection Technique in China Compared with the Rest of the World. Diabetes Ther 2018; 9:2357-2368. [PMID: 30377996 PMCID: PMC6250623 DOI: 10.1007/s13300-018-0525-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Approximately 9 million people in China use insulin but little is known of their injection techniques (IT). Our aim was to understand IT in China via direct examination and a detailed survey. METHODS Injection Technique Questionnaire (ITQ) results of 3853 patients from 20 representative centers in China were compared with the Rest of World (ROW). RESULTS Insulin pens are used by 92% of Chinese insulin injectors, with > 3/4 using 4- or 5-mm pen needles. This is consistent with Chinese BMI values (and thus subcutaneous fat thickness) being lower than in ROW, raising the risk of IM (intramuscular) injections with longer needles. Total daily insulin dose is ~ 33 IU in China vs. 45 IU elsewhere. Lipohypertrophy (LH) rates are lower than in ROW, but still found in at least 25% of Chinese patients. Patients apparently do not realize they have LH or are unaware of the hazards of injecting into LH since many of them do so, and those who do use a mean of 11 IU more of insulin than non-LH patients. This incremental insulin use possibly costs the Chinese health care service around 2 billion RMB annually. Needle reuse is also frequent in China (78% vs. 48% ROW), and the high cost of pen needles is the main reason patients cite for reusing (25% use a single needle > 10×). CONCLUSION This study reveals many areas in which Chinese professionals and patients can optimize injection practices and thereby improve outcomes and reduce costs. The official guidelines of the Chinese Diabetes Society, based on the FITTER recommendations, offer a roadmap for reaching this goal. FUNDING BD Diabetes Care. Plain language summary available for this article.
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Affiliation(s)
- Zhenqiang Song
- Collaborative Innovation Center of Tianjin for Medical Epigenetics, Key Laboratory of Hormones and Development (Ministry of Health), Metabolic Diseases Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Xiaohui Guo
- Peking University First Hospital, Beijing, China
| | - Linong Ji
- Department of Endocrinology, People's Hospital of Peking University, Xicheng District, Beijing, China
| | - Xiao Huang
- Tianjin Metabolic Hospital, Metabolic Diseases Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
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Kapeluto JE, Paty BW, Chang SD, Meneilly GS. Ultrasound detection of insulin-induced lipohypertrophy in Type 1 and Type 2 diabetes. Diabet Med 2018; 35:1383-1390. [PMID: 29908078 DOI: 10.1111/dme.13764] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
AIMS To define standard criteria for the detection of lipohypertrophy using ultrasonography and to determine the accuracy of this method. METHOD Individuals using insulin therapy for ≥2 years with unknown lipohypertrophy status were enrolled at a diabetes education centre. A team of diabetes educator nurses performed a clinical examination for evidence of lipohypertrophy and a separate team of ultrasonographers examined participants in a blinded fashion. RESULTS The echo signature for lipohypertrophy consisted of location in the subcutaneous layer and lesions that were 1) well circumscribed either by hyperechoic foci with defined borders or a nodular shape with a hypoechoic halo, 2) heterogeneous in echotexture compared with surrounding tissue, 3) associated with distortion of surrounding connective tissue with 4) absence of vascularity and 5) absence of capsule. Ultrasonography identified individuals with lipohypertrophy significantly more frequently than inspection or palpation (P<0.0001). Inter-observer agreement was moderate (κ=0.50) and limited by the presence of subclinical lesions in 73% of the participants. CONCLUSIONS The ultrasound detection of lipohypertrophy is consistent with clinical examination and is reproducible using a defined echo signature. (ClinicalTrials.gov registration no: NCT02348099).
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Affiliation(s)
- J E Kapeluto
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - B W Paty
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - S D Chang
- Department of Radiology, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - G S Meneilly
- Division of Geriatric Medicine, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
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Dagdelen S, Deyneli O, Olgun N, Siva ZO, Sargin M, Hatun S, Kulaksizoglu M, Kaya A, Gürlek CA, Hirsch LJ, Strauss KW. Turkish Insulin Injection Techniques Study: Complications of Injecting Insulin Among Turkish Patients with Diabetes, Education They Received, and the Role of Health Care Professional as Assessed by Survey Questionnaire. Diabetes Ther 2018; 9:1615-1628. [PMID: 29961244 PMCID: PMC6064601 DOI: 10.1007/s13300-018-0463-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Using the Turkish and rest of world (ROW) Injection Technique Questionnaire (ITQ) data we address key insulin injection complications. METHODS Summarized in first ITQ paper. RESULTS Nearly one-third of Turkish insulin users described lesions consistent with lipohypertrophy (LH) at their injection sites and 27.4% were found to have LH by the examining nurse (using visual inspection and palpation). LH lesions in the abdomen and thigh of Turkish patients are slightly smaller than those measured in ROW but more than half of Turkish patients who have LH continue to inject into them at least daily. More than a quarter of Turkish patients have frequent unexplained hypoglycemia and nearly 2 out of 5 have glycemic variability, both of which have been linked to the presence of LH and the habit of injecting into it. Nearly half of Turkish injectors report having pain on injection. Of these, just over half report having painful injections only several times a month or year (i.e., not with every injection). In Turkey the diabetes nurse has by far the major role in teaching patients how to inject. Nearly 40% of Turkish injectors get their sites checked at least annually, and a larger proportion than ROW had received recent (within the last 12 months) instruction on how to inject properly. CONCLUSION Turkish patients and professionals have clearly made progress in injection technique, but there are still considerable challenges ahead which the new Turkish guidelines will help address. FUNDING BD Diabetes Care.
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Affiliation(s)
- Selcuk Dagdelen
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Hacettepe Mah., 06230, Sıhhıye, Ankara, Turkey
| | - Oguzhan Deyneli
- Department of Endocrinology and Metabolism, Koc University School of Medicine, Davutpasa Cad. No: 4, 34010, Topkapı, Istanbul, Turkey
| | - Nermin Olgun
- Nursing Department, Faculty of Health Sciences, Hasan Kalyoncu University, Havaalanı Yolu Üzeri 8. km, Sahinbey, Gaziantep, Turkey
| | - Zeynep Osar Siva
- Department of Endocrinology, Diabetes and Metabolism, Cerrahpasa School of Medicine, Istanbul University, Cerrahpasa Mah. Kocamustafapasa Cad. No: 53, 34098, Fatih, Istanbul, Turkey
| | - Mehmet Sargin
- Faculty of Medicine, Istanbul Medeniyet University, Egitim Mah. Dr. Erkin Cad., 34722, Kadıköy, Istanbul, Turkey
| | - Sükrü Hatun
- Department of Pediatric Endocrinology and Diabetes, Koc University School of Medicine, Davutpasa Cad. No: 4, 34010, Topkapı, Istanbul, Turkey
| | - Mustafa Kulaksizoglu
- Department of Endocrinology and Metabolism, Meram Faculty of Medicine, Necmettin Erbakan University, Yunus Emre Mah. Beysehir Cad. No: 281, 42080, Meram, Konya, Turkey
| | - Ahmet Kaya
- Department of Endocrinology and Metabolism, Meram Faculty of Medicine, Necmettin Erbakan University, Yunus Emre Mah. Beysehir Cad. No: 281, 42080, Meram, Konya, Turkey
| | - Cansu Aslan Gürlek
- BD Diabetes Care, Ruzgarlibahce Mah. S.Sinan Eroglu Cad. No: 6, Akel Is Merkezi A Blok -3. Kat, Kavacik, 34805, Beykoz, Istanbul, Turkey
| | | | - Kenneth W Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium.
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Tsadik AG, Atey TM, Nedi T, Fantahun B, Feyissa M. Effect of Insulin-Induced Lipodystrophy on Glycemic Control among Children and Adolescents with Diabetes in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. J Diabetes Res 2018; 2018:4910962. [PMID: 30116742 PMCID: PMC6079411 DOI: 10.1155/2018/4910962] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Lipodystrophy is one of the clinical complications of insulin injection that affects insulin absorption and leads to poor glycemic control. OBJECTIVE To assess insulin-induced lipodystrophy and glycemic control. METHODS A cross sectional study was done on 176 diabetic children and adolescents who inject insulin for a minimum of one year. First, anthropometric and clinical characteristics of the patients were recorded in questionnaire, and then observation and palpation techniques were used in assessing lipodystrophy. RESULT Out of the total 176 participants, 103 (58.5%) had insulin-induced lipodystrophy, of them 100 (97.1%) had lipohypertrophy and 3 (2.9%) had lipoatrophy. Being younger, failure to rotate the injection site every week and multiple reuse of insulin syringe had significant influence in development of insulin-induced lipohypertrophy. Lipohypertrophy in turn was associated with the use of higher dose of insulin and nonoptimal glycemic control. CONCLUSION Findings of this study revealed that in spite of using recombinant human insulin, the magnitude of the lipohypertrophy still remained high. Therefore, a routine workup of insulin-injecting patients for such complication is necessary, especially in the individuals who have a nonoptimal glycemic control.
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Affiliation(s)
- Afewerki Gebremeskel Tsadik
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Tesfay Mehari Atey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Teshome Nedi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bereket Fantahun
- Department of Pediatrics, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mamo Feyissa
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Gupta SS, Gupta KS, Gathe SS, Bamrah P, Gupta SS. Clinical Implications of Lipohypertrophy Among People with Type 1 Diabetes in India. Diabetes Technol Ther 2018; 20:483-491. [PMID: 29932731 DOI: 10.1089/dia.2018.0074] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) at insulin injection sites is a common but preventable complication in type 1 diabetes mellitus (T1DM). We evaluated the prevalence, contributing risk factors, and consequences of LH, specifically the glycemic variability (GV) among T1DM patients. METHODS This is a cross-sectional study conducted at a tertiary care center in India, wherein 139 subjects with T1DM were randomly selected and evaluated for the presence of LH through visual and palpation examinations. Demography, anthropometry, and injecting practices were evaluated using a validated questionnaire and their effect on LH was determined. Subsequently, the effect of LH on GV and unexplained hypoglycemia (UH) was studied. Mean glucose, mean amplitude of glycemic excursions (MAGEs), and continuous overlapping net glycemic action (CONGA) were assessed in a subset of patients who injected insulin alternately in LH and non-LH sites. RESULTS The overall prevalence of LH was 69.8%, and was significantly higher in adults than in children (P = 0.038). Improper rotation of sites (P < 0.0001) and insulin syringe reusage for more than five times (P = 0.009) significantly increase the risk of LH. The presence of LH has a significant effect on GV and UH with adjusted odds ratios of 17.65 (P < 0.0001) and 28.02 (P < 0.0001), respectively. Ambulatory glucose monitoring on a subset of patients confirmed that the mean glucose, MAGE, and CONGA were higher when subjects injected insulin at LH sites than at non-LH sites. CONCLUSIONS Improper rotation of sites and reuse of needles are the leading causes of LH in Indian T1DM patients, which, in turn, significantly increases the risk of GV and UH.
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Affiliation(s)
- Sunil S Gupta
- 1 Department of Diabetology, Sunil's Diabetes Care n' Research Centre , Nagpur, India
| | - Kavita S Gupta
- 2 Research Scholar, Rashtrasant Tukdoji Maharaj Nagpur University, MS, India and Department of Dietetics and Diabetes Education, Sunil's Diabetes Care n' Research Centre Pvt. Ltd. , Nagpur, India
| | - Sachin S Gathe
- 3 Department of Clinical Research and Epidemiology, Sunil's Diabetes Care n' Research Centre Pvt. Ltd. , Nagpur, India
| | | | - Shlok S Gupta
- 5 Student, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur; Maharashtra University of Health Sciences (Nashik), India
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Barola A, Tiwari P, Bhansali A, Grover S, Dayal D. Insulin-Related Lipohypertrophy: Lipogenic Action or Tissue Trauma? Front Endocrinol (Lausanne) 2018; 9:638. [PMID: 30425682 PMCID: PMC6218430 DOI: 10.3389/fendo.2018.00638] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 10/08/2018] [Indexed: 12/16/2022] Open
Abstract
Lipohypertrophy has been suggested as an outcome of lipogenic action of insulin and/or injection-related tissue trauma. In a cross-sectional study, we evaluated the predictors of lipohypertrophy in 372 type 1 diabetes patients (mean age 17.1 years) receiving subcutaneous insulin with pen and/or syringes for ≥3 months. On examining injection sites with inspection and palpation technique, 62.1% patients demonstrated lipohypertrophy. Univariate analysis showed that gender, BMI, HbA1c, injection device, rotation, injection area, needle length, insulin regimen, and total daily dose of insulin were associated with lipohypertrophy (p < 0.05). Notably, the mean needle reuse was comparable in patients with or without lipohypertrophy (8.1 vs. 7.2, p = 0.534). In multivariate logistic regression, gender, HbA1c, TDD, injection devices, and needle length lost its significance. Further, injections over smaller area (≤8.5 × 5.5 cm) and non-rotation of sites were found to be strongest independent predictor of lipohypertrophy (p < 0.0005 for both) with increased odds of 23.2 (95% CI 9.1-59.2) and 6.3 (95% CI 3.4-11.9) times, respectively. Being underweight was also a significant independent predictor (odds ratio [OR] 13.0 [95% CI 2.2-75.2], p = 0.004). Compared to rapid plus long-acting analogs, regular insulin plus long-acting analogs and conventional premixed insulin users had 3.2 (95% CI 1.5-6.8, p = 0.003) and 4.6 (95% CI 1.4-15.7, p = 0.014) fold higher risk of lipohypertrophy (mean injection frequency 4.01 vs. 4.01 vs. 2.09, respectively). Sub-group analysis showed that lipohypertrophy was 79% less likely in patients with multiple daily injections (≥4) than twice-daily regimen (OR 0.21, p < 0.0005). Moreover, lipohypertrophy was reduced to half with bolus doses of rapid-acting insulin analogs than regular insulin (p = 0.003), even though mean injection frequency was comparable (4.01 vs. 3.93, p = 0.229). This difference was statistically insignificant for basal doses with NPH or long-acting analogs (p = 0.069). Therefore, injection area, rotation, BMI, and insulin regimen are the best predictors of lipohypertrophy and together could correctly identify lipohypertrophy status in 84.4% patients with excellent discrimination capability (AUC = 0.906, p < 0.0005). In conclusion, findings of our study suggest that delivering rapidly absorbed insulin analogs over large injection area along with greater split of total daily doses reduce insulin-induced lipogenesis and outplay tissue trauma added through frequent injections and needle reuse.
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Affiliation(s)
- Anjana Barola
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Pramil Tiwari
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- *Correspondence: Anil Bhansali
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devi Dayal
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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15
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Campinos C, Le Floch JP, Petit C, Penfornis A, Winiszewski P, Bordier L, Lepage M, Fermon C, Louis J, Almain C, Morel D, Hirsch L, Strauss KW. An Effective Intervention for Diabetic Lipohypertrophy: Results of a Randomized, Controlled, Prospective Multicenter Study in France. Diabetes Technol Ther 2017; 19:623-632. [PMID: 29058477 PMCID: PMC5750448 DOI: 10.1089/dia.2017.0165] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) is highly prevalent and is potentially harmful to insulin-injecting patients. METHODS In this study, we assessed the impact of injection technique (IT) education, including use of a 4-mm pen needle on insulin-treated patients with clinically observed LH in a randomized, controlled, prospective multicenter study in France with follow-up of 6 months. Intensive education and between-visit reinforcement were given to the intervention group. Control patients received similar messages at study outset. RESULTS A total of 123 patients were recruited (age 52.1 ± 15.7 years; men 70.7%; body mass index >30 kg/m2: 34.2%; type 1: 53.7%; years with diabetes mellitus: 18.1 ± 10.5), of which 109 patients were included in the final analysis. The intervention group (n = 53) showed a significant decrease of total daily dose of insulin (average at baseline: 54.1 IU) at 3 months (T-3) and 6 months (T-6), reaching just over 5 IU versus baseline (P = 0.035). Corresponding, although not significant, decreases occurred in controls (n = 56); between-group differences were not significant. There were significant decreases in HbA1c (up to 0.5%) at T-3 and T-6 in both groups, with no significant differences between groups. A significant number of intervention patients improved their IT habits; about half achieved ideal IT habits by T-3 versus a quarter of control patients. By T-6, 2/3 of intervention patients achieved either ideal or acceptable IT habits, while only 1/3 of control patients did. CONCLUSIONS Our intervention was effective in both study arms, however, to a greater degree and more rapidly in the intervention group. Widespread application of this intervention could be highly cost-effective.
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Affiliation(s)
| | | | - Catherine Petit
- CH Sud Francilien Diabetes Service, Corbeil-Essonnes, France
| | - Alfred Penfornis
- Université Paris Sud Diabetes Service, CH Sud Francilien, Corbeil-Essonnes, France
| | | | - Lyse Bordier
- H.I.A. Begin Diabetes Service, Saint Mande, France
| | - Marie Lepage
- C.H.B. Diabetes Service, Boulogne sur Mer Cedex, France
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Ortiz-Roa C, Pinilla-Roa AE. Efecto de la lipohipertrofia en el control metabólico de pacientes con diabetes mellitus tipo 2. REVISTA DE LA FACULTAD DE MEDICINA 2017. [DOI: 10.15446/revfacmed.v65n4.53108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
La lipodistrofia (lipohipertrofia, lipoatrofia) es una complicación dada por la técnica inadecuada de inyección subcutánea de insulina. Se presenta el caso de una paciente de 46 años con diabetes mellitus tipo 2 descontrolada, en tratamiento con insulina glargina 45UI/día, sin control glucométrico y con múltiples ajustes y hospitalizaciones. Al ingreso, el automonitoreo muestra glucometrías basales y posprandiales fuera de metas, glucemia basal de 299 mg/dL y HbA1c de 11%. Al interrogatorio, se evidencian fallas en la técnica de aplicación de insulina, en particular falta de rotación del sitio de aplicación. En el examen físico se encuentra lipohipertrofia dada por panículo adiposo infraumbilical prominente bilateral e induración del tejido celular subcutáneo; en ecografía se visualiza infiltración grasa de rectos anteriores. Se da instrucción a la paciente sobre la correcta técnica de aplicación de insulina con rotación diaria del sitio de aplicación, descanso de zonas con lipohipertrofia y guía para automonitoreo.El automonitoreo en los 10 primeros días mostró mejoría de glucometrías basales hasta 116 mg/dL y valor limítrofe de 75 mg/dL, comparados con promedio de glucometría basal previa de 242 mg/dL con la misma insulina y dosis. Se hizo seguimiento estrecho para definir dosis requerida de insulina y vigilar posible hipoglucemia, con mejoría en la HbA1c de 9.2% y 8.8% a los 4 y 11 meses, respectivamente.
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Deng N, Zhang X, Zhao F, Wang Y, He H. Prevalence of lipohypertrophy in insulin-treated diabetes patients: A systematic review and meta-analysis. J Diabetes Investig 2017; 9:536-543. [PMID: 28862814 PMCID: PMC5934253 DOI: 10.1111/jdi.12742] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 08/06/2017] [Accepted: 08/21/2017] [Indexed: 01/10/2023] Open
Abstract
AIMS/INTRODUCTION Insulin-treated diabetes patients are at high risk for lipohypertrophy (LH), but this clinical problem has been overlooked by some medical professionals. In addition, studies differed from each other significantly in regard to the prevalence of LH. The present systematic review aimed to determine pooled prevalence levels of LH among insulin-injecting diabetes patients. MATERIALS AND METHODS Four electronic databases (PubMed, EMBASE, The Cochrane Library and Scopus) were searched for eligible studies from their inception until April 2017, and reference lists were searched manually to identify additional studies. Studies containing data on LH in patients with diabetes mellitus were included. Meta-analysis was carried out with a random effects model. RESULTS A total of 26 studies with a total of 12,493 participants met the inclusion criteria. Meta-analysis showed that the pooled prevalence of LH was 38% (95% confidence interval [CI] 29-46%, I2 = 99.1%). The main influence on LH was the type of diabetes mellitus. The pooled prevalence of LH among patients with type 2 diabetes mellitus was higher than patients with type 1 diabetes mellitus (49%, 95% CI 23-74% vs 34%, 95% CI 19-49%). The pooled prevalence of LH of studies involving a mixed type of diabetes mellitus was 37% (95% CI 25-48%, I2 = 98.3%). CONCLUSION The prevalence of LH was high in insulin-treated diabetes patients. It showed that diabetes nurses should screen for LH regularly in their patients, and teach them how to prevent LH in their daily management of diabetes mellitus.
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Affiliation(s)
- Nan Deng
- Department of NursingAffiliated Hospital of Nantong UniversityNantongChina
- Nursing School of Nantong UniversityNantongChina
| | - Xiaoyi Zhang
- Department of EndocrinologyAffiliated Hospital of Nantong UniversityNantongChina
| | | | - Ya Wang
- Nursing School of Nantong UniversityNantongChina
| | - Hong He
- Department of NursingAffiliated Hospital of Nantong UniversityNantongChina
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Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B, Ghosh S, Sanyal D, Hirsch LJ, Gupta V, Strauss KW. Indian Injection Technique Study: Injecting Complications, Education, and the Health Care Professional. Diabetes Ther 2017; 8:659-672. [PMID: 28289892 PMCID: PMC5446373 DOI: 10.1007/s13300-017-0244-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Using the Indian and rest of world (ROW) injection technique questionnaire (ITQ) data, we address key insulin injection complications. METHODS In 2015 we conducted an ITQ survey throughout India involving 1011 patients. Indian values were compared with those from 41 other countries participating in the ITQ, known here as ROW. RESULTS More than a quarter of Indian insulin users described lesions consistent with lipohypertrophy (LH) at their injection sites and approximately 1 in 5 were found to have LH by the examining nurse (using visual inspection and palpation). Just over half of Indian injectors report having pain on injection. Of these, 4 out of 5 report having painful injections only several times a month or year (i.e., not with every injection). Doctors and diabetes educators in India (as opposed to nurses) have a larger role in teaching patients how to inject than they do in ROW. Despite this specialized approach, a very high percentage of patients report that they have not been trained (at least cannot remember being trained) in a wide range of essential injection topics. Only about 30% of Indian injectors get their sites checked at least annually, with nearly a third only having sites checked when they specifically complained and nearly 4 out of 10 never having had their sites checked. CONCLUSION Indian HCPs can clearly do a better job covering all the vital topics essential to proper injection habits.
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Affiliation(s)
| | - Ambrish Mithal
- Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, India
| | - Rakesh Sahay
- Osmania Medical College, Turrebaz Khan Rd, Esamiya Bazaar, Koti, Hyderabad, Telangana, India
| | - Mathew John
- Providence Endocrine and Diabetes Specialty Centre, TC 1/2138, Near GG Hospital, Murinjapalam, Thiruvananthapuram, Kerala, India
| | - A G Unnikrishnan
- Chellaram Diabetes Institute, Pune-Bangalore, NH4, Bavdhan, Pune, Maharashtra, India
| | - Banshi Saboo
- Diacare-Diabetes Care and Hormone Clinic, 1 and 2 Gandhi Park Society, Nehrunagar Cross Roads, Ambavadi, Ahmedabad, Gujarat, India
| | - Sujoy Ghosh
- AMRI Medical Centre Kolkata, No. 97 A, Southern Avenue, Above Maruti Showroom, Opposite Lake Stadium, Kolkata, West Bengal, India
| | - Debmalya Sanyal
- KPC Medical College and Hospital, Kolkata, F, Raja Subodh Chandra Mullick Road, Jadavpur, Near Jadavpur Railway Station, Kolkata, West Bengal, India
| | | | - Vandita Gupta
- BD Diabetes Care, BD, 6th Floor Signature Tower-B, South City I, NH 8, Gurgaon, Haryana, India
| | - Kenneth W Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium.
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Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B, Ghosh S, Sanyal D, Hirsch LJ, Gupta V, Strauss KW. Indian Injection Technique Study: Population Characteristics and Injection Practices. Diabetes Ther 2017; 8:637-657. [PMID: 28289893 PMCID: PMC5446372 DOI: 10.1007/s13300-017-0243-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION It was estimated that 3.2 million Indians with diabetes injected insulin in 2010, but little is known about the techniques used. METHODS In 2015 we conducted an injection technique questionnaire (ITQ) survey throughout India involving 1011 patients. Indian values were compared with those from 41 other countries participating in the ITQ, known here as rest of world (ROW). RESULTS Mean HbA1c was 8.6. BMI values in India were 1.5-3 units lower than in ROW depending on patient group, meaning the risk of intramuscular (IM) injections is high in India. The mean total daily dose (TDD) of insulin was lower in every category of Indian patient than in ROW, perhaps reflecting the lower BMI. Needle reuse, whether with pens or syringes, is much higher in India than ROW and so is the number of times the needle is used. The majority (56.8%) of Indian insulin users performed only 2 injections/day as opposed to ROW where 45% of patients performed at least 4 injections/day. Indian patients inject insulin in the thighs more often than patients in ROW, a site where IM injections are more risky. Many patients do not have proper access to sharps containers or have other risk factors that could lead to blood-borne pathogen spread. More than 60% of used sharps in India go into the rubbish, with nearly 12% not even having the minimum protection of a cap. DISCUSSION The shortest needles are very common in India; however, the level of needle reuse is high. Multiple daily injections therapy is not as common in India as ROW. More focus needs to be given to dwell times under the skin, reconstitution of cloudy insulins, skinfolds, and safe sharps disposal.
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Affiliation(s)
| | - Ambrish Mithal
- Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurgaon, Haryana, India
| | - Rakesh Sahay
- Osmania Medical College, Turrebaz Khan Rd, Esamiya Bazaar, Koti, Hyderabad, Telangana, India
| | - Mathew John
- Providence Endocrine & Diabetes Specialty Centre, TC 1/2138, Near GG Hospital, Murinjapalam, Thiruvanthapuram, Kerala, India
| | - A G Unnikrishnan
- Chellaram Diabetes Institute, Pune-Bangalore, NH4, Bavdhan, Pune, Maharashtra, India
| | - Banshi Saboo
- Diacare-Diabetes Care & Hormone Clinic, 1 & 2 Gandhi Park Society, Nehrunagar Cross Roads, Ambavadi, Ahmedabad, Gujarat, India
| | - Sujoy Ghosh
- AMRI Medical Centre Kolkata, No. 97 A, Southern Avenue, Above Maruti Showroom, Opposite Lake Stadium, Kolkata, West Bengal, India
| | - Debmalya Sanyal
- KPC Medical College and Hospital, Raja Subodh Chandra Mullick Road, Jadavpur, Near Jadavpur Railway Station, Kolkata, West Bengal, India
| | - Laurence J Hirsch
- BD Diabetes Care, 1 Becton Dr. MC 378, Franklin Lakes, New Jersey, USA
| | - Vandita Gupta
- BD Diabetes Care, BD, 6th Floor Signature Tower-B, South City I, NH 8, Gurgaon, Haryana, India
| | - Kenneth W Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium.
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Hernar I, Haltbakk J, Broström A. Differences in depression, treatment satisfaction and injection behaviour in adults with type 1 diabetes and different degrees of lipohypertrophy. J Clin Nurs 2017; 26:4583-4596. [DOI: 10.1111/jocn.13801] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Ingvild Hernar
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Faculty of Health and Social Sciences; Department of Nursing; Western Norway University of Applied Sciences; Bergen Norway
| | - Johannes Haltbakk
- Faculty of Health and Social Sciences; Department of Nursing; Western Norway University of Applied Sciences; Bergen Norway
| | - Anders Broström
- Faculty of Health and Social Sciences; Department of Nursing; Western Norway University of Applied Sciences; Bergen Norway
- Department of Nursing Science; Jönköping University; Jönköping Sweden
- Department of Clinical Neurophysiology; University Hospital Linköping; Linköping Sweden
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Smith M, Clapham L, Strauss K. UK lipohypertrophy interventional study. Diabetes Res Clin Pract 2017; 126:248-253. [PMID: 28288434 DOI: 10.1016/j.diabres.2017.01.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/18/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Lipohypertrophy (LH) is one of the most common complications of insulin therapy. We conducted a prospective study in 18 UK centres to assess the impact of a targeted LH intervention on a range of clinical, biological and socio-economic parameters. METHODS Seventy-five insulin-injecting patients were recruited randomly and were followed prospectively for 3-6months, with results compared to baseline values. Interventions included the use of an intensive education program and a switch to a 4mm pen needle. RESULTS At all injection sites LH decreased significantly by the end of the study, either disappearing completely or shrinking by approximately 50% from its original diameter. Injections into LH decreased by more than 75% by the end. Most patients were not correctly rotating injection sites at the beginning but by the end most were, by a 5-fold margin. Only 1/3 of our subjects used the 4mm needle at the beginning of the study, however, virtually all did by study end. The mean HbA1c improved by more than 4mmol/L and there were significantly lower levels of unexpected hypoglycaemia and glucose variability. Total daily doses of insulin dropped by an average of 5.6 IU by study end. CONCLUSIONS We believe the impressive clinical improvements seen with training to prevent LH can be achieved by wide adoption of the interventions outlined in this study.
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Affiliation(s)
- Mike Smith
- BD Diabetes Care, The Danby Building, Edmund Halley Road, Oxford Science Park, Oxford OX4 4DQ, UK.
| | - Linda Clapham
- Wharfedale Diabetes Centre, Wharfedale Hospital, Newall Carr Road, Otley, Leeds Teaching Hospitals, LS21 2LY Leeds, UK.
| | - Kenneth Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, B-9320 Erembodegem, Belgium.
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Ji L, Sun Z, Li Q, Qin G, Wei Z, Liu J, Chandran AB, Hirsch LJ. Lipohypertrophy in China: Prevalence, Risk Factors, Insulin Consumption, and Clinical Impact. Diabetes Technol Ther 2017; 19:61-67. [PMID: 28099050 DOI: 10.1089/dia.2016.0334] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) is a complication of insulin therapy. We assessed LH prevalence, risk factors, insulin usage, and clinical and health economic effects in China. METHODS In four cities, 401 adult patients injecting insulin ≥1 year were surveyed for diabetes/insulin injection history and practices, pen needle reimbursement (PNR), and health resource utilization, followed by structured examination and HbA1c testing. Differences between those with and without LH were evaluated by Student's t-test or the Wilcoxon rank sum test. Insulin costs were calculated. RESULTS Patients were 59.6 ± 11.5 years old; 50% male; 93.5% type 2 diabetes. LH prevalence was 53.1%. Compared to those without LH, patients with LH had higher body mass index (BMI; 26 vs. 24.8 kg/m2) and HbA1c (8.2% vs. 7.7% [66 vs. 61 mmol/mol]), took 11 IU (0.13 IU/kg or 31.7%) more insulin costing $1.4 versus $1.0 (RMB 9.5 vs. 6.8) daily, reused PNs more times, and had less PNR (all P ≤ 0.003). LH patients correctly rotated injection sites less often (67.6% vs. 92.3%, P < 0.0001). By stepwise logistic regression, BMI, needle reuse frequency, and PNR remained modestly associated with LH prevalence (odds ratios [OR] <1.9; P ≤ 0.03); weight-adjusted insulin dose and incorrect site rotation showed ORs of nearly 7 and 8.4, respectively (P ≤ 0.001). Extrapolated to 9 million insulin-injecting patients in China and adjusted for therapy adherence, LH-related excess annual insulin consumption cost is estimated at nearly $297 million (RMB 2 billion). CONCLUSIONS LH is common in China and associated with worse glycemic control, despite nearly one-third greater insulin consumption, with large cost implications. Proper injection technique education may reduce LH prevalence.
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Affiliation(s)
- Linong Ji
- 1 Department of Endocrinology, Peking University People's Hospital , Beijing, China
| | - Zilin Sun
- 2 Department of Endocrinology, Southeast University Zhongda Hospital , Nanjing, China
| | - Qifu Li
- 3 Department of Endocrinology, Chongqing Medical University First Affiliated Hospital , Chongqing, China
| | - Guijun Qin
- 4 Department of Endocrinology, Zhengzhou University First Affiliated Hospital , Zhengzhou, China
| | - Zheng Wei
- 5 BD (Becton Dickinson, Inc.) Medical Affairs , Beijing, China
| | - Junhao Liu
- 5 BD (Becton Dickinson, Inc.) Medical Affairs , Beijing, China
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Frid AH, Kreugel G, Grassi G, Halimi S, Hicks D, Hirsch LJ, Smith MJ, Wellhoener R, Bode BW, Hirsch IB, Kalra S, Ji L, Strauss KW. New Insulin Delivery Recommendations. Mayo Clin Proc 2016; 91:1231-55. [PMID: 27594187 DOI: 10.1016/j.mayocp.2016.06.010] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 12/14/2022]
Abstract
Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.
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Affiliation(s)
- Anders H Frid
- Department of Endocrinology, Skane University Hospital, Malmö, Sweden
| | - Gillian Kreugel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Giorgio Grassi
- Città della Salute e della Scienza Torino, Torino, Italy
| | - Serge Halimi
- University for Sciences and Medicine Joseph Fourier Grenoble and Diabetology Department CHU Grenoble, Grenoble Cedex, France
| | - Debbie Hicks
- Barnet, Enfield & Haringey Mental Health Trust, London, UK
| | | | | | | | | | - Irl B Hirsch
- University of Washington Medical Center-Roosevelt, Seattle
| | | | - Linong Ji
- Peking University Peoples Hospital, Beijing, China
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Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. DIABETES & METABOLISM 2013; 39:445-53. [DOI: 10.1016/j.diabet.2013.05.006] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/05/2013] [Accepted: 05/12/2013] [Indexed: 11/24/2022]
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Hansen B, Matytsina I. Insulin administration: selecting the appropriate needle and individualizing the injection technique. Expert Opin Drug Deliv 2011; 8:1395-406. [PMID: 21864222 DOI: 10.1517/17425247.2011.614229] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Patients with diabetes who receive insulin therapy often fail to meet their targets for metabolic control with insulin injections. Their inadequate glycemic control may be related to incorrect injection procedure. AREAS COVERED This review examines the latest data related to insulin injection and needle characteristics, which play an integral role in patient satisfaction. Searches of Medline and Cumulative Index to Nursing and Allied Health Literature databases were conducted. Results show that optimal insulin injection can facilitate glycemic control in pediatric and adult patients. In general, needles shorter than 8 mm are appropriate for normal weight, obese pediatric and adult patients. However, body mass index, gender, race, age and injection site can influence the depth of subcutaneous tissue and thus, the desired needle size and injection technique. Although the abdomen, thighs and buttocks are all recommended injection sites, abdominal injections disperse insulin slightly more rapidly than thigh injections. EXPERT OPINION Wider acceptance of needles shorter than 6 mm will occur with more evidence of their safety and efficacy, particularly in children. Development of shorter and thinner needles to make injections even easier and less burdensome may be expected in the future.
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Affiliation(s)
- Birtha Hansen
- Aarhus University Hospital, Medical Endocrinology Department MEA, Noerrebrogade 44, 8000 Aarhus C, Denmark.
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Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, Letondeur C, Sauvanet JP, Tubiana-Rufi N, Strauss K. The Third Injection Technique Workshop in Athens (TITAN). DIABETES & METABOLISM 2010; 36 Suppl 2:S19-29. [PMID: 20933206 DOI: 10.1016/s1262-3636(10)70003-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The first Injection Technique workshop brought together endocrinologists and injection experts from around the world in Strasbourg in 1997. From its work came groundbreaking recommendations which advanced best practices in areas such as the use of a skin fold when injecting. The second Injection Technique workshop, with an expanded format including nurses and diabetes educators, took place in Barcelona in 2000. The initial stimulus to use shorter injecting needles can be said to date from this meeting. The third Injection Technique workshop was held in Athens in September 2009 and involved 127 experts from across the globe. After a comprehensive review of all publications since 2000 as well as several unpublished studies, the attendees divided into smaller groups to debate and draft new injecting recommendations based on the new data and their collective experience. This paper summarizes all the formal presentations given at this practical consensus workshop.
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Affiliation(s)
- A Frid
- Endocrinologist, Clinic of Endocrinology, Skåne University Hospital, Malmö, Sweden
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Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, Letondeur C, Sauvanet JP, Tubiana-Rufi N, Strauss K. New injection recommendations for patients with diabetes. DIABETES & METABOLISM 2010; 36 Suppl 2:S3-18. [PMID: 20933208 DOI: 10.1016/s1262-3636(10)70002-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM Injections administered by patients are one of the mainstays of diabetes management. Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy. Yet few formal guidelines have been published summarizing all that is known about best practice. We propose new injection guidelines which are thoroughly evidence-based, written and vetted by a large group of international injection experts. METHODS A systematic literature study was conducted for all peer-reviewed studies and publications which bear on injections in diabetes. An international group of experts met regularly over a two-year period to review this literature and draft the recommendations. These were then presented for review and revision to 127 experts from 27 countries at the TITAN workshop in September, 2009. RESULTS Of 292 articles reviewed, 157 were found to meet the criteria of relevance to the recommendations. Each recommendation was graded by the weight it should have in daily practice and by its degree of support in the medical literature. The topics covered include The Role of the Professional, Psychological Challenges, Education, Site Care, Storage, Suspension and Priming, Injecting Process, Proper Use of Pens and Syringes, Insulin analogues, Human and Pre-mixed Insulins, GLP-1 analogs, Needle Length, Skin Folds, Lipohypertrophy, Rotation, Bleeding and Bruising, Pregnancy, Safety and Disposal. CONCLUSION These injecting recommendations provide practical guidance and fill an important gap in diabetes management. If followed, they should help ensure comfortable, effective and largely complication-free injections.
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Affiliation(s)
- A Frid
- Endocrinologist, Clinic of Endocrinology, Skåne University Hospital, Malmö, Sweden
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Kordonouri O, Maguire AM, Knip M, Schober E, Lorini R, Holl RW, Donaghue KC. Other complications and associated conditions with diabetes in children and adolescents. Pediatr Diabetes 2009; 10 Suppl 12:204-10. [PMID: 19754631 DOI: 10.1111/j.1399-5448.2009.00573.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Olga Kordonouri
- Diabetes Center for Children and Adolescents, Children's Hospital auf der Bult, Hannover, Germany.
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Kordonouri O, Maguire AM, Knip M, Schober E, Lorini R, Holl RW, Donaghue KC. ISPAD Clinical Practice Consensus Guidelines 2006-2007. Other complications and associated conditions. Pediatr Diabetes 2007; 8:171-6. [PMID: 17550428 DOI: 10.1111/j.1399-5448.2007.00249.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Lipohypertrophy has been a recognized complication of insulin therapy for many years, yet research shows that its prevalence in insulin-injecting patients with diabetes remains high. The problem for the patient is that the injection of insulin into a site of lipohypertrophy, although painless, may lead to erratic absorption of the insulin, with the potential for poor glycaemic control and unpredictable hypoglycaemia. Despite the important implications of this for diabetes control in insulin-injecting patients, there is a dearth of information and completed research into the condition. This article raises awareness of lipohypertrophy by reviewing the available literature on the prevention, identification and management of the condition from a nursing perspective. Recommendations for medical and nursing practice in diabetes care to improve prevention and management of lipohypertrophy are made.
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Johansson UB, Amsberg S, Hannerz L, Wredling R, Adamson U, Arnqvist HJ, Lins PE. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care 2005; 28:2025-7. [PMID: 16043749 DOI: 10.2337/diacare.28.8.2025] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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