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Kalus A, Shinohara MM, Wang R, Baran JD, Dong X, Khakpour D, Lu J, Hirsch IB. Evaluation of Insulin Pump Infusion Sites in Type 1 Diabetes: The DERMIS Study. Diabetes Care 2023; 46:1626-1632. [PMID: 37450710 DOI: 10.2337/dc23-0426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Continuous subcutaneous insulin infusion (CSII) for type 1 diabetes is increasing in use. Pump site failures are common, but little is known about skin changes from pump use. Using noninvasive optical coherence tomography (OCT), OCT angiography (OCTA), and skin biopsies, we evaluated skin changes from chronic insulin infusion. RESEARCH DESIGN AND METHODS In this cross-sectional study, OCT operating at a 1,310-nm central wavelength with a bandwidth of 100 nm was performed immediately before skin punch biopsies were collected at three sites: the current site, with the infusion set removed at time of OCT and biopsy; the recovery site, with the infusion set removed 3 days before biopsy; and the control site, which was never used for any insulin infusion or injection. RESULTS OCT and OCTA identified characteristics of increased inflammation and vessel density at pump sites compared with control sites. Histologic analysis of pump sites showed differences in skin architecture, including fibrosis, inflammation (including increased tissue eosinophils), and fat necrosis. Immunohistochemical staining showed differences between infusion and control sites regarding staining of ILGF-I and transforming growth factor-β3. CONCLUSIONS These findings support allergic sensitization as a potentially common reaction at CSII sites. The leading candidates causing this include insulin preservatives, plastic materials, and adhesive glue used in device manufacturing. The inflammatory response caused by these common allergic responses may result in tissue changes responsible for the infusion site failures seen frequently in clinical practice.
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Affiliation(s)
- Andrea Kalus
- Division of Dermatology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Michi M Shinohara
- Division of Dermatology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Ruikang Wang
- Department of Bioengineering, University of Washington, Seattle, WA
| | - Jesica D Baran
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Xiaofu Dong
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Dori Khakpour
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Jie Lu
- Department of Bioengineering, University of Washington, Seattle, WA
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
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Kesserwan S, Sadagurski M, Mao L, Klueh U. Mast Cell Deficiency in Mice Attenuates Insulin Phenolic Preservative-Induced Inflammation. Biomedicines 2023; 11:2258. [PMID: 37626754 PMCID: PMC10452641 DOI: 10.3390/biomedicines11082258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
One major obstacle that limits the lifespan of insulin infusion pumps is surmounting the tissue site reaction at the device implantation site. All commercial insulin formulations contain insulin phenolic preservatives (IPPs) designed to ensure insulin protein stability and prolong shelf-life. However, our laboratory demonstrated that these preservatives are cytotoxic and induce inflammation. Mature mast cells (MCs) reside in cutaneous tissue and are one of the first responders to an epidermal breach. Upon activation, MCs release proinflammatory and immunomodulatory prepacked mediators that exacerbate these inflammatory reactions. Thus, we hypothesized that once the epidermis is breached, cutaneous MCs are triggered inciting the inflammatory response to IPP-induced inflammation. This hypothesis was pursued utilizing our modified in vivo mouse air pouch model, including a c-kit dependent (C57BL/6J-kitW-sh/W-sh) and a c-kit independent (Cpa3-Cre; Mcl-1fl/fl) MC-deficient mouse model. Leukocytes were quantified in the mouse air pouch lavage fluid following flow cytometry analysis for IPP infusion under three different states, insulin-containing phenolic preservatives (Humalog®), insulin preservatives alone, and normal saline as a control. The air pouch wall was assessed using histopathological evaluations. Flow cytometry analysis demonstrated a statistically significant difference in inflammatory cell recruitment for both MC-deficient mouse models when compared to the control strain including infused control saline. Significantly less inflammation was observed at the site of infusion for the MC-deficient strains compared to the control strain. Overall, concordant results were obtained in both mouse types, C57Bl6-kitW-sh/W-sh and Cpa3-Cre; Mcl-1fl/fl. These findings in multiple model systems support the conclusion that MCs have important or possible unique roles in IPP-induced inflammation.
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Affiliation(s)
| | | | | | - Ulrike Klueh
- Integrative Biosciences Center (IBio), Wayne State University, Detroit, MI 48202, USA; (S.K.); (M.S.)
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Huang J, Yeung AM, Kerr D, Gentile S, Heinemann L, Al-Sofiani ME, Joseph JI, Seley JJ, Klonoff DC. Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks. Endocr Pract 2023:S1530-891X(23)00386-5. [PMID: 37098370 DOI: 10.1016/j.eprac.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To review the current status of practical knowledge related to insulin-associated lipohypertrophy (LH) - an accumulation of fatty subcutaneous nodules commonly caused by repeated injections and/or infusions of insulin into the same site. METHODS Review of published literature with additional contributions from leading multidisciplinary experts with the emphasis on clinical aspects including pathophysiology, clinical and economic consequences, diagnosis, prevention and treatment. RESULTS LH is the most common dermatologic complication of insulin therapy. Risk factors for the development of lipohypertrophy include repeated delivery of large amounts of insulin into the same location over time, repeated injection trauma to the skin and subcutaneous tissue, and multiple injections using the same needle. Subcutaneous insulin injection in skin areas with lipohypertrophy is associated with reduced pain; however, this problem can interfere with insulin absorption, thereby increasing the likelihood of glucose variability, hypo- and hyperglycemia when a site is changed. Modern visualization technology of the subcutaneous space with ultrasound can demonstrate lipohypertrophy early in the course of its development. CONCLUSIONS The physiological and psychological consequences of developing insulin lipohypertrophy can be prevented and treated with education focusing on insulin injection techniques.
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Affiliation(s)
- Jingtong Huang
- Diabetes Technology Society, Burlingame, California, USA.
| | - Andrea M Yeung
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, California, USA
| | - Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy; NefroCenter Research Network, Torre del Greco, Naples, Italy
| | | | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jeffrey I Joseph
- Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, California, USA; Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
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Ardilouze JL, Gobeil F, Cheng R, Ménard J, Bovan D, Messier V, Savard M, Baillargeon JP, Rabasa-Lhoret R. Can a Mixture of Insulin and a Nonsteroidal Anti-inflammatory Drug Prolong Insulin Pump Catheter Wear Time in Adults With Type 1 Diabetes? Can J Diabetes 2023; 47:180-184. [PMID: 36050255 DOI: 10.1016/j.jcjd.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jean-Luc Ardilouze
- Endocrinology Division, University of Sherbrooke, Sherbrooke, Québec, Canada; Research Centre of the Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
| | - Fernand Gobeil
- Research Centre of the Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada; Pharmacology-Physiology Department, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Ran Cheng
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Endocrinology Division, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Julie Ménard
- Research Centre of the Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Danijela Bovan
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Virginie Messier
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Martin Savard
- Pharmacology-Physiology Department, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Jean-Patrice Baillargeon
- Endocrinology Division, University of Sherbrooke, Sherbrooke, Québec, Canada; Research Centre of the Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Endocrinology Division, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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