The management of lipohypertrophy in diabetes care

Local complications of insulin administration sites and effect on diabetes management

BACKGROUND

Administration of insulin may be associated with substantial cutaneous adverse effects, such as lipoatrophy and lipohypertrophy (LH), which can cause glycemic excursions above and below the target levels for blood glucose. Our aim was to evaluate the effect on compliance with the use of insulin administration site, dermatological complications and diabetes management in children with type 1 diabetes (T1D).

METHODS

Patients aged 0 - 21 years who were followed up with the diagnosis of T1D for at least one year were included. A 14-question survey including demographic characteristics and a subjective opinion of skin-related complications of insulin administration was given. Data were obtained from the medical records to evaluate the effect of dermatological complications on diabetes management. This study was checked with the STROBE checklist.

RESULTS

Two hundred and fifty-four patients were included and 53% of these were female. The mean age was 14.9 ± 4.7 years and the duration of T1D was 7.3 ± 4.1 years. The mean HbA1c level was 8 ± 1.4% and the mean total insulin dose was 0.84 ± 0.25 units/kg/day. More than half of the individuals (57%) were receiving multiple daily injections (MDI) and 43% were on insulin pump therapy (IPT). Of the participants, 11.8% reported LH, 7.5% wound, 21.7% allergy, 55.5% bleeding, 41.3% bruising and 47.2% pain. LH rates varied significantly by regimen, 17.1% in MDI and 4.6% with IPT (p = .001). Those with LH were using higher median doses of insulin (0.97 U/kg/day) than those who did not (0.78 U/kg/day; p = .016). LH was reported more frequently (18.3%) in patients with frequent hypoglycemia (p = .007). Positive correlation between BMI-SDS and LH in patients aged <18 years was found (p = .043). LH rates by site were: right arm 20.8%, left arm 26.4%, right abdomen 26.4%, left abdomen 22.6% and 1% in the right and left leg.

CONCLUSIONS

Local complications of insulin therapy are common in young patients with T1D. The complication with the most impact on metabolic control was LH, present in nearly 12% of patients. Users of IPT have a significantly lower risk of LH. The results emphasise the importance of individualised education for young T1D patients and their families about injection site preference and rotation techniques.

RELEVANCE TO CLINICAL PRACTICE

The diabetes team should check the insulin administration sites of children with type 1 diabetes at each visit and provide repeated education about the dermatological complications of insulin.

Lactobacillus salivarius AP-32 and Lactobacillus reuteri GL-104 decrease glycemic levels and attenuate diabetes-mediated liver and kidney injury in db/db mice

OBJECTIVES

Patients with type 2 diabetes mellitus (T2DM) exhibit strong insulin resistance or abnormal insulin production. Probiotics, which are beneficial live micro-organisms residing naturally in the intestinal tract, play indispensable roles in the regulation of host metabolism. However, the detailed mechanisms remain unclear. Here, we evaluate the mechanisms by which probiotic strains mediate glycemic regulation in the host. The findings should enable the development of a safe and natural treatment for patients with T2DM.

RESEARCH DESIGNS AND METHODS

Sugar consumption by more than 20 strains of Lactobacillus species was first evaluated. The probiotic strains that exhibited high efficiency of sugar consumption were further coincubated with Caco-2 cells to evaluate the regulation of sugar absorption in gut epithelial cells. Finally, potential probiotic strains were selected and introduced into a T2DM animal model to study their therapeutic efficacy.

RESULTS

Among the tested strains, Lactobacillus salivarius AP-32 and L. reuteri GL-104 had higher monosaccharide consumption rates and regulated the expression of monosaccharide transporters. Glucose transporter type-5 and Na⁺-coupled glucose transporter mRNAs were downregulated in Caco-2 cells after AP-32 and GL-104 treatment, resulting in the modulation of intestinal hexose uptake. Animal studies revealed that diabetic mice treated with AP-32, GL-104, or both showed significantly decreased fasting blood glucose levels, improved glucose tolerance and blood lipid profiles, and attenuated diabetes-mediated liver and kidney injury.

CONCLUSION

Our data elucidate a novel role for probiotics in glycemic regulation in the host. L. salivarius AP-32 and L. reuteri GL-104 directly reduce monosaccharide transporter expression in gut cells and have potential as therapeutic probiotics for patients with T2DM.

Using probiotics for type 2 diabetes mellitus intervention: Advances, questions, and potential

Type 2 diabetes mellitus (T2DM) has become one of the most prevalent diseases on earth and several treatments have been developed. However, the current intervention approaches have not been as effective as expected. One promising supplementary strategy is the use of probiotics through direct or indirect approaches. Probiotics are microbial food cultures conferring health-promoting properties. In this review, we summarized the current theories and mechanisms of T2DM intervention using probiotics and hypothesize that probiotics intervene T2DM during its onsetting, developing, and complicating. For the first time, we comprehensively analyzed T2DM intervention in animal models using both wide-type probiotics in different forms and using recombinant probiotics. Then, probiotic intervention in T2DM patients was reviewed and the main results were compared with that obtained from animal studies. Finally yet importantly, remaining questions that are important such as in which form and in which state, as well as the future potential of probiotic intervention in T2DM were discussed from a perspective of food microbiologists. In conclusion, probiotic intervention in T2DM is promising but there are still many important issues unsolved yet. Critical review of the advances, questions, and potential of probiotic intervention in T2DM promotes the development of this approach for further application in humans.

Lipohypertrophic Skin Changes in Patients With Diabetes: Visualization by Infrared Images

BACKGROUND

Many patients with diabetes on insulin therapy develop lipohypertrophies (LHTs). So far, LHTs are diagnosed by conventional methods (CM; visual inspection, palpation and/or ultrasound). In everyday life, it would be advantageous to have a quick, simple and inexpensive alternative, for example, diagnosing them by obtaining infrared (IR) images.

METHODS

We obtained IR images from 43 subjects (21 patients with type 1 diabetes, conventional subcutaneous insulin therapy and known LHTs, 8 patients with CSII and LHTs, 7 patients without LHTs, and 7 healthy people), all from one specialized diabetes practice. The IR images were taken under standardized conditions with a high-resolution infrared camera (VarioCam® HDx Jenoptic, IR pixel 640 × 480, thermal resolution 0.003K) and compared with LHT diagnoses with CM.

RESULTS

In 14 of the 29 (48%) patients, CM diagnosed LHTs were "cold spots" in the IR images. The temperature difference to "healthy" skin (without LHTs) was up to 6°C. Of the 14 patients, 11 also showed such spots, without findings with CM. Four patients did not show clearly identifiable cold spots as LHT and 2 patients showed no changes in the IR images. The remaining 9 patients did not show clearly identifiable cold spots as LHT, but the diagnosis with CM was also ambiguous.

CONCLUSIONS

The results of this small (pilot) study do not clearly support the value of IR images for the diagnosis of LHTs, but they do not refute this approach. Diagnosis of LHT might be hampered due to the existence of different types of LHTs. Usage of IR images can apparently detect LHTs before they can be diagnosed with CM. Further targeted investigations are required to make statements about the usability of this method.

Effect of Insulin-Induced Lipodystrophy on Glycemic Control among Children and Adolescents with Diabetes in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

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.

Clinical Implications of Lipohypertrophy Among People with Type 1 Diabetes in India

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.

Ultrasound characterization of insulin induced lipohypertrophy in type 1 diabetes mellitus

OBJECTIVE

Subcutaneous insulin absorption is one of the key factors affecting glycemic control in patients with diabetes mellitus under insulin therapy. Insulin-induced subcutaneous lipohypertrophy has been reported to impair insulin regular absorption and hence glycemic control. So far, lipohypertrophy diagnosis has only been clinical. This study aims at evaluating the possible role of ultrasound scan in the assessment of subcutaneous lipohypertrophy in patients affected by type 1 diabetes mellitus.

METHODS

A pilot observational retrospective study was performed in 20 patients affected by type 1 diabetes mellitus. In these patients the areas with clinical evidence of lipohypertrophy dependent on the insulin injections were characterized by the presence of tissues that at the ultrasound scan resulted similar to fibrotic tissues (hyperechogenic) or to an interstitial edema or to fat tissues (hypoechogenic). It was utilized a multi frequency linear probe (6-18 MHz). The patients were advised to avoid insulin injections on the areas with lipohypertrophy scanned by the ultrasound and the HbA1c changes were evaluated 3 months later.

RESULTS

The lipohypertrophic areas presented at least three different aspects upon ultrasound assessment: the iso-hyperechogenic one, with a predominant fibrotic component; the isoechogenic one, with "large tangles" fibrotic elements and the iso-hypoechogenic aspect with no fibrotic elements. When patients were advised to avoid insulin injections on areas with lipohypertrophy defined by ultrasound scan, 3 months after the first evaluation HbA1c had significantly improved (basal HbA1c 7.87 ± 0.56 versus 7.67 ± 0.52 3 months later, p = 0.029). No significant improvements of the HbA1c were found in the control matched group in which lipohypertrophy was only clinically valued through inspection and palpation.

CONCLUSIONS

Ultrasound scan can help identify and characterize the lipohypertrophic areas and this might be useful to improve glycemic control.

New Insulin Delivery Recommendations

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.

Frequency of Lipohypertrophy and Associated Risk Factors in Young Patients with Type 1 Diabetes: A Cross-Sectional Study

INTRODUCTION

The objective of this study was to investigate the frequency of lipohypertrophy (LH) and the associated risk factors in young patients with type 1 diabetes mellitus (T1DM).

METHODS

This cross-sectional study was conducted on a sample of 174 patients with T1DM (aged 13-18 years) treated with multiple daily insulin injections for a minimum duration of 1 year. The study was performed at the Diabetes Treatment Center, Prince Sultan Military Medical City (Riyadh, Saudi Arabia), between July 2015 and September 2015. Information regarding patients' age, weight, height, adjusted body mass index (BMI), period of the diabetic condition, length of needle used, number of injections per day, injection locations, insulin regimen, and glycosylated hemoglobin (HbA1c) were recorded. LH was assessed using the palpation technique.

RESULTS

Nearly 46% of patients were found to reuse needles, while 42.5% failed to alternate the injection site and 23% revealed unexplained hypoglycemic events. A substantial percentage of patients (approximately 47%) showed grade 1 LH, followed by 33.7% with grade 2 and 19.3% with grade 3 LH. A higher frequency of LH was observed in the thigh region (n = 28, 33.7%) than in the arm, which was second highest (n = 23, 27.7%). Patients aged ≥16 years showed a higher frequency of LH than those aged <16 years. Patients with uncontrolled diabetes mellitus had a greater likelihood of having LH (59.5%) than those with controlled diabetes (20.8%). Significant differences in LH were observed based on needle length, needle reuse, and rotation of the injection sites. On performing regression analysis, the independent risk factors for LH were found to be as follows: higher BMI, higher HbA1c, a higher number of injection sites, a higher rate of needle reuse and failed to alternate the injection site.

CONCLUSION

As the frequency of LH was found to be high in Saudi patients with T1DM, it is essential to educate patients on the risk factors for LH and on diabetic control.

Prevalence of lipohypertrophy and associated risk factors in insulin-treated patients with type 2 diabetes mellitus

BACKGROUND

Secondary failure of oral hypoglycemic agents is common in patients with type 2 diabetes mellitus (T2DM); thus, patients often need insulin therapy. The most common complication of insulin treatment is lipohypertrophy (LH).

OBJECTIVES

This study was conducted to estimate the prevalence of LH among insulin-treated patients with Patients with T2DM, to identify the risk factors for the development of LH, and to examine the association between LH and glycemic control.

PATIENTS AND METHODS

A total of 1090 patients with T2DM aged 20 to 89 years, who attended the diabetes clinics at the National Center for Diabetes, Endocrinology, and Genetics (NCDEG, Amman, Jordan) between October 2011 and January 2012, were enrolled. The presence of LH was examined by inspection and palpation of insulin injection sites at the time of the visit as relevant clinical and laboratory data were obtained. The LH was defined as a local tumor-like swelling of subcutaneous fatty tissue at the site of repeated insulin injections.

RESULTS

The overall prevalence of LH was 37.3% (27.4% grade 1, 9.7% grade 2, and 0.2% grade 3). The LH was significantly associated with the duration of diabetes, needle length, duration of insulin therapy, lack of systematic rotation of insulin injection sites, and poor glycemic control.

CONCLUSIONS

The LH is a common problem in insulin-treated Jordanian patients with T2DM. More efforts are needed to educate patients and health workers on simple interventions such as using shorter needles and frequent rotation of the insulin injection sites to avoid LH and improve glycemic control.

Insulin administration: selecting the appropriate needle and individualizing the injection technique

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.

Lipohypertrophy in children and adolescents with type 1 diabetes and the associated factors

Background

Despite the important implications of lipohypertrophy for diabetes control, there is a dearth of information and research about the subject in children. The aim of this study was to study the prevalence of lipohypertrophy in children with type 1 diabetes, and to evaluate the associated factors.

Findings

119 children coming for regular follow up in the diabetes clinic were examined for the presence of lipohypertrophy by inspection and palpation. The last 4 readings of glycated hemoglobin (HbA1c) levels and other factors that may affect lipohypertrophy were documented. RESULTS: The patient's age ranged from 2 months to 21 years with a median of 10 years (inter-quartile range = 6). Lipohypertrophy occurred in 54.9% of patients, more commonly in males (62.7%) vs. females (48.4%) (P = 0.074). Grade 1 lipohypertrophy occurred in 42.5% and grade 2 in 12.4%. Lipohypertrophy was related significantly to the dose of insulin units per kg of body weight (Odds ratio [OR] = 16.4; 95% CI, 2.2 - 124.6; P = 0.007), the duration of diabetes, [OR] = 1.16; 95% CI, 1.05 - 1.32; P = 0.004)), and the body mass index (BMI) [OR] = 1.68; 95% CI, 1.25 - 2.15; P = 0.006). The mean HbA1c levels of patients with grade 1 and grade 2 lipohypertrophy did not differ from diabetics without lipohypertrophy (F = 0.178, P = 0.837)

Conclusions

The presence of lipohypertrophy was significantly associated with the duration of diabetes and the body mass index. Children with lipohypertrophy needed a significantly higher dose of insulin units/kg of body weight to achieve fair control compared to children without lipohypertrophy. Further studies are needed to ascertain the clinical meaning of these findings.

Metabolic consequences of incorrect insulin administration techniques in aging subjects with diabetes

Only few insulin-treated (IT) people with diabetes mellitus (DM) reach the target due to poor compliance and/or to sedentary lifestyle and/or to inadequate treatment regimen. The latter may be also brought about by often overlooked factors including insulin injection into altered skin areas, often brought about by incorrect habits, namely needle reutilization or poor compliance to the suggestion to continuously rotate skin injection areas. The aim of our study was to evaluate the rate of skin lesions within the sites commonly used for insulin injection in our IT DM patients and to verify whether a short-acting insulin analogue yielded different metabolic effects when injected in altered vs. normal skin areas. One hundred and eighty well-trained IT people with type 1 and type 2 DM (64 ± 15 years of age) consecutively referring to our unit underwent a standard clinical examination involving an accurate skin inspection protocol meant at looking for any alterations eventually affecting all possible injection sites, including bruising, multiple needle pricks and lipodystrophic nodules (LN). They were also tested for HPLC HbA1c determination and asked to fill in a standard questionnaire on injection habits. Furthermore, seven male, T1DM glulisine-glargine basal-bolus-treated patients in this group were randomly injected 10 IU glulisine into either normal skin (NS) or an LN by a nurse before a standard, 405 kcal breakfast, for blood glucose and free insulin determination at 0, 30, 45, 60, 75, 90, 120 and 150 min. More lesions were found in people over sixty (P < 0.01) and in women (P < 0.05). A higher prevalence of HbA1c >7.5% was found in patients with lesions (with an O.R. of 3.74) and further confirmed by data obtained from head-to-head comparison of insulin injection into an LN and NS. In fact, injection into an LN proved to impair and slow down insulin absorption, resulting in a higher absolute value and a larger variability of blood glucose levels than those observed by utilizing NS. This suggests us to pay more attention to all aspects of patient-team relationship to try and obtain good metabolic control in all people with diabetes and even more in the elderly.

New injection recommendations for patients with diabetes

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.