Insulin injection lipoatrophy recidivus

Prevalence of skin problems caused by insulin pump therapy and associated factors in children with type 1 diabetes mellitus: A large cross-sectional survey in China

AIMS

To document the prevalence of skin problems associated with insulin pump use and identify contributing factors among children with type 1 diabetes mellitus in China.

METHODS

In total, 461 children were recruited from an online community (i.e., a Wechat group) of pediatric patients with T1DM. A self-developed questionnaire was filled in by parents, collecting the information on social demographics, disease, and insulin pump therapy related characteristics and skin problems. We applied the Mann-Whitney U test, Chi square test and logistic regression analysis to identify the factors associated with skin problems.

RESULTS

Of the 461 responders, 308 (66.8 %) children were reported to have skin problems. More specifically, 38.8 % had pigmentation changes, 22.3 % allergy/dermatitis, 20.2 % scaring, 11.5 % pain, 10.8 % infection, 10.6 % subcutaneous lipohypertrophy, and 6.1 % lipoatrophy. Logistic regression analysis showed that independent associated factors of skin problems were the caregiver's educational level as college or above, patient having skin allergies, and using the Brand 2 insulin pump (p values < 0.05).

CONCLUSIONS

The present study documents the prevalence of skin problems and identifies associated factors, such as caregiver's education, patients skin allergies, and using a specific brand of pump. Health education should address these factors in addition to the traditionally emphasized factors.

The Impact of Insulin-Induced Lipodystrophy on Glycemic Variability in Pediatric Patients with Type 1 Diabetes

Lipodystrophy is the most common dermatological complication in patients with diabetes on insulin therapy. Despite the high frequency of lipodystrophy, there are still several difficulties in giving advice about avoidance into practice among children and adolescents with type 1 diabetes and their caregivers. This cross-sectional study aims to evaluate the prevalence of insulin-induced lipodystrophy in a cohort of pediatric patients with type 1 diabetes, to identify associated clinical factors and to assess its influence on glycemic control. Two hundred and twelve patients attending our Diabetes Center during a three-month period were enrolled. The presence of lipodystrophy was assessed by inspection and palpation procedures. Demographic and clinical data including type of treatment, frequency of rotation of insulin administration sites, and glucose metrics of the previous 30 days were assessed and statistically analyzed. Prevalence of lipohypertrophy was 44.3%. Two patients were affected by lipoatrophy (0.9%). Improper rotation of insulin administration sites and low awareness on lipodystrophy were associated to the occurrence of this skin condition (p = 0.050 and p = 0.005, respectively). When comparing patients with and without lipodystrophy, a significant difference in glycemic variability parameters was detected (p = 0.036 for coefficient of variation, p = 0.029 for standard deviation score of glucose levels). Lipodystrophy still represents a common complication in patients on insulin therapy. The present study reveals its negative impact on glycemic variability. This finding emphasizes the importance of prevention strategies to minimize the occurrence of this dermatological complication that may interfere with clinical history of the disease.

Lipoatrophy, a rare complication of diabetes: a single-center experience

BACKGROUND

Lipoatrophy (LA), a rare skin complication in patients with type 1 diabetes (T1D), has decreased dramatically over the past decades due to the use of human purified insulin preparations.

METHODS

We collected data from the records of T1D patients with LA. Types of insulin and insulin regimen, presence of eosinophilia, anti-insulin (IAA), anti-GAD, anti-IA2 autoantibodies, other autoimmune disorders, site of atrophy and its relationship to catheter, HbA1c at LA onset and after resolution, and different treatment modalities (i.e., change of insulin type or site, sodium cromoglycate (SCG) cream, cortisone cream or percutaneous injections, and laser treatment) were recorded.

RESULTS

Thirteen out of 1200 T1D subjects (1%) presented with LA. The majority were on insulin pump using rapid-acting analogs. Twelve out of 13 patients had changed the type of insulin, and most of them had switched injection sites. Ten out of 13 patients used SCG cream and 7/10 showed complete/partial improvement. One patient used dexamethasone injection with improvement. Five patients showed self-improvement. In 3/7 patients who were receiving SCG, treatment was combined with change of insulin type (glulisine); however, in 1/3, the result should be attributed to concomitant laser treatment. In 4/7 patients, there was a clear, beneficial effect of SCG. In 1/4 with partial resolution of LA, laser treatment was used after SCG, which further improved the result.

CONCLUSIONS

LA is a rare skin complication seen even today with the use of insulin analogs. SCG alone or combined with change of insulin type seems to be the most effective treatment. Laser treatment is a promising new therapy.

Cutaneous Adverse Effects of Diabetes Mellitus Medications and Medical Devices: A Review

Diabetes mellitus is one of the most prevalent chronic diseases in the USA. If uncontrolled, diabetes can lead to devastating complications. Diabetes medications and medical devices largely contribute to the significant financial expense that the disease inflicts on affected individuals and society. Alongside significant economic burden, there are numerous cutaneous adverse effects associated with diabetes medications and medical devices. Despite the large and increasing number of individuals living with diabetes and the wide use of the related medications and medical devices, there is limited literature that comprehensively documents their cutaneous adverse effects. These cutaneous adverse effects are significant as they can worsen glycemic control, increase disease distress, and may increase risk of associated complications. Thus, it is important that providers can recognize these cutaneous adverse effects, identify the culprit agents, and can properly manage them. In this article, we provide a critical review of the cutaneous adverse effects of medications and devices used in the management of diabetes and provide insight into risk factors and prevention and an overview of therapeutic management. An emphasis is placed on clinical recognition and treatment for use of the medical providers who, regardless of practice setting, will treat patients with diabetes.

Clinical review: insulin pump-associated adverse events in adults and children

AIMS

Insulin pumps are a vital and rapidly developing tool in the treatment of type 1 diabetes mellitus in both adults and children. Many studies have highlighted outcomes and assessed their potential advantages, but much of the data on adverse outcomes are limited and often based on outdated technology. We aimed to review and summarize the available literature on insulin pump-associated adverse events in adults and children.

METHODS

A literature search was undertaken using PubMed, EMBASE, and the Cochrane library. Articles were then screened by title, followed by abstract, and full text as needed. A by-hand search of reference lists in identified papers was also utilised. All searches were limited to English language material, but no time limits were used.

RESULTS

Current and past literature regarding insulin pump-associated adverse events is discussed, including potential metabolic and non-metabolic adverse events, in particular: pump malfunction; infusion set/site issues; and cutaneous problems. We show that even with modern technology, adverse events are common, occurring in over 40 % of users per year, with a minority, particularly in children, requiring hospital management. Hyperglycaemia and ketosis are now the most common consequences of adverse events and are usually associated with infusion set failure. This differs from older technology where infected infusion sites predominated.

CONCLUSIONS

This timely review covers all potential insulin pump-associated adverse events, including their incidence, features, impacts, and contributory factors such as the pump user. The importance of ongoing anticipatory education and support for patients and families using this intensive insulin technology is highlighted, which if done well should improve the overall experience of pump therapy for users, and hopefully reduce the incidence and impact of severe adverse events.

Detemir plus aspart and glulisine induced lipoatrophy: 2015 literature review and report of a new case

BACKGROUND

In the first and only literature review, conducted in 2009, of human insulin analog- induced lipoatrophy, there were 12 published cases, including 1 with aspart, 1 with detemir, 1 with NovoMix 30 and none with detemir plus aspart. It is perceived that insulin analog induced-lipoatrophy is increasing. We conducted a 2015 literature review of published reports of lipoatrophy induced by aspart, detemir, detemir plus aspart, and NovoMix30. We also report a new case of detemir plus aspart and glulisine induced lipoatrophy.

METHODS

Our focused literature searches (limited to 1995-2014) in PubMed, Embase, and Web of Science, using a combination of insulin analog and lipoatrophy terminology, was conducted in early January 2015.

RESULTS

From the 520 unique citations there were 33 (from 13 papers and 9 abstracts) lipoatrophy cases induced by detemir (n = 5), aspart (n = 21), detemir plus aspart (n = 4) and NovoMix 30 (n = 3), representing 30 new cases since 2009. Many of these reported cases were females (76 %), had type 1 diabetes mellitus (T1DM) (94 %) and were in young persons (61 %). A 41-year-old T1DM woman developed lipoatrophy on her upper thighs, arms and abdomen 14 months after injecting detemir plus aspart at the same sites. Later on, after a year on continuous subcutaneous insulin infusion (CSII) using aspart and then glulisine, she developed lipoatrophy at the infusion sites. When CSII insulin was switched to lispro she did not develop lipoatrophy after 10 months. Meanwhile, the original lipoatrophy sites significantly improved.

CONCLUSIONS

Our literature review uncovered 30 new published cases of aspart, detemir, aspart plus detemir and NovoMix 30-induced lipoatrophy since 2009. The largest increase in cases was in aspart- induced lipoatrophy. Recent surveys showed most rapid acting insulin analog-induced lipoatrophy were associated with CSII. In our review of the reported cases, 85.7 % cases of aspart-induced lipoatrophy were associated with CSII. As in previous reports, we showed lipoatrophy was more common in females, T1DM and young persons. Our patient may be the 5^th published case of detemir plus aspart-induced lipoatrophy and possibly the first case report of glulisine induced lipoatrophy. She believed both detemir plus aspart and glulisine induced the lipoatrophy.

Lipoatrophy in children with type 1 diabetes: an increasing incidence?

The objectives were to evaluate the current prevalence of lipoatrophy at insulin injection sites in young patients with type 1 diabetes. Standardized examination of insulin injection sites in all 678 patients with type 1 diabetes treated in 2013 in our outpatient clinic were conducted. In case of lipoatrophy photo documentation and standardized interview with parents and patients were performed. We identified a total of 16 patients (43.8% male) with lipoatrophy (overall prevalence 2.4%). The current mean age (±SD) of the affected patients was 14.4 ± 3.9 years, age and diabetes duration at onset of lipoatrophy were 11.5 ± 3.8 years and 5.4 ± 3.6 years, respectively. All patients were using analogs at the onset of lipoatrophy. In all, 14 of 16 patients (87.5%) were on insulin pump compared with 52% without lipoatrophy (P = .0018). The use of steel needle and Teflon catheter was equal between the pump patients. Concomitant autoimmune diseases were present in 37.5% of the patients (thyroiditis: n = 3, thyroiditis and celiac disease: n = 2, celiac disease: n = 1) compared with 15.0% in those without lipoatrophy (P = .0128). Lipoatrophy was present in young patients treated with modern insulins and pumps; however, the prevalence was relatively low as expected with the use of modern insulins. Our data may support the hypothesis that a constant mechanical element such as a subcutaneous catheter may trigger the development of lipoatrophy, particularly in those patients with more than 1 autoimmune disease.