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

Prevalence and associated factors of lipodystrophy in type 1 diabetic children and adolescents at Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia

INTRODUCTION

Lipodystrophy can cause poor glycemic control in addition to cosmetic problems in children and adolescents with type 1 diabetes mellitus. However, data on its prevalence and associated factors is scarce among children and adolescents who live in developing countries like Ethiopia.

OBJECTIVE

To determine the prevalence and identify associated factors of lipodystrophy in children and adolescents with type 1 diabetes mellitus who visited the endocrinology clinic of Ayder Comprehensive Specialized Hospital between May 1 and July 31, 2020.

METHOD

This was an institution-based cross-sectional study conducted on 57 children and 65 adolescents with type 1 diabetes mellitus who had been taking insulin injections for a year or more. The dependent variable was lipodystrophy. A pretested, structured questionnaire was used to collect data related to lipodystrophy and other characteristics. The principal investigator oversaw the data collection, which was done by pediatric and child health specialty residents with training. Data was subjected to descriptive statistics, and predictors of lipodystrophy were identified by fitting a multivariable logistic regression model. Statistical significance was declared at p < 0.05.

RESULTS

More than half (53.3%) of patients were in the age range of 13 to 17. The male-to-female ratio was almost 1:1. Educational status for 63.1% of patients was primary school. Four-fifths of patients were residing in urban areas. Of the 122 participants, 60 (49.2%) had lipodystrophy (48.3% lipohypertrophy and 0.8% lipoatrophy), with grade II lipohypertrophy being the most common type at 81.7%. The thigh was the most common site of lipodystrophy. In multivariable regression analysis, the long duration of insulin injection (AOR = 3.6, 95% CI, 1.5 to 9.0, p = 0.005) and inappropriate rotation of the injection site (AOR = 9.0, 95% CI, 2.2 to 37.0, p = 0.002) were significantly associated with lipodystrophy. HbA1c testing was conducted for 70 patients, and poor glycemic control (HbA1c ≥ 7%) was found in 43 (61.4%) of them. Patients with lipodystrophy were more likely to have poor glycemic control (75%) than those without lipodystrophy (47.1%) (p = 0.016).

CONCLUSION

The prevalence of lipodystrophy was comparable with other studies. Long duration of insulin injection and improper rotation of the injection site are associated with an increased risk of lipodystrophy. Patients with lipodystrophy were more likely to have poor glycemic control, defined by higher HgA1c, than those without lipodystrophy. Proper education of patients and their parents must include correct injection techniques, rotating injection sites, and changing injection sites intermittently to lessen the risk of developing lipodystrophy.

Are People With Type 1 Diabetes Mellitus Appropriately Following Insulin Injection Technique Practices: A Review of Literature

People with type 1 diabetes mellitus (T1DM) need to take multiple doses of insulin injections daily throughout their lives. However, a notable portion of people with diabetes mellitus (DM) show suboptimal insulin injection technique practices. They are supposed to follow the recommended insulin injection technique guidelines. Our explorative literature search, including studies from the past 30 years, is expected to identify the deficiencies of self-injection insulin techniques and the associated complications in people with T1DM, where we have summarised the overall incidence of complications that have occurred due to nonadherence of the prescribed guidelines, along with their associated risk factors. We have attempted to include multiple systematic reviews, meta-analyses, literature reviews, case reports, and original articles from the search engines and databases like PubMed, Scopus, ScienceDirect, Cochrane Library, Google Scholar, and BioMed Central, and studies with only human participants were included in this search. The knowledge sharing from this research may be utilised for enhancing the structured education diabetes programme and implementing the population-based corrective measures, including the thrust areas in future multi-centre longitudinal research studies and recommendations, which can prevent unnecessary complications and enhance their quality of life. Correct insulin administration technique, abstaining from administration of injection at the areas with lipohypertrophy, rotation of injection sites, and ultrasound scanning can be used as a complimentary method to detect the lipohypertrophy at an early stage. Liposuction is beneficial in reducing the extensive lipohypertrophic tissues but helps achieve only cosmetically satisfactory outcome; thus, empowering people to follow insulin injection technique guidelines is one of the best strategies to reduce the high prevalence of lipohypertrophy. To conclude, education among the people with DM, especially T1DM who have to take insulin regularly, needs to be carried out consistently in the clinical settings, to prevent the severe complications caused due to inappropriate insulin injection techniques.

Lipohypertrophy and Insulin: An Update From the Diabetes Technology Society

Lipohypertrophy is a common skin complication associated with insulin-treated diabetes. The impact of lipohypertrophy as a contributing factor to suboptimal glycemic control, glucose variability, and hypoglycemia is often under-recognized by health care professionals. In a recent Webinar on April 26, 2023, Diabetes Technology Society asked international experts to provide updates on the latest knowledge related to lipohypertrophy for practicing clinicians and educators, researchers, and industries involved in insulin delivery. A recording of the Webinar is freely available on the Diabetes Technology Society Web site (https://www.diabetestechnology.org/).

Prevalence and associated factors of lipohypertrophy in insulin-injected patients with diabetes in selected primary care clinics in Peninsular Malaysian: A cross-sectional study

Introduction

This study aimed to determine the prevalence and associated factors of lipohypertrophy in insulin-injecting patients with diabetes at selected primary care clinics in Malaysia.

Method

This cross-sectional study was conducted among adults aged ≥18 years with type 1 or 2 diabetes treated with insulin for at least 6 months at six selected public primary care clinics in Malaysia. The Injection Technique Questionnaire was used, and physical examination was conducted to detect the presence of lipohypertrophy. Univariate and multivariate logistic regression analyses were conducted using IBM SPSS version 26.

Results

A total of 506 patients with type 2 diabetes were included in this study; of them, 60.47% were women, and 48.42% were Malays. The prevalence of lipohypertrophy was 39.6% (95% Confidence Interval, CI =35%-44%). The univariate analysis revealed that a larger number of injections per day, longer needle length, repeated use of needles, incorrect rotation of the injection site, longer insulin use duration, higher total insulin dose and higher HbA1c level were significantly associated with lipohypertrophy. In the multivariate logistic regression analysis, incorrect rotation of the injection site was the only independent associated factor of lipohypertrophy.

Conclusion

The prevalence of lipohypertrophy in this study is comparable with that in other studies. The identified associated factors of lipohypertrophy must be addressed in ongoing health education for insulin-injecting patients at Malaysian primary care clinics. Educating healthcare professionals and increasing awareness among patients with diabetes are important steps in preventing this complication.

Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks

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.

Effect of Insulin Injection Techniques on Glycemic Control Among Patients with Diabetes

Objective

Previous studies have shown that healthcare professionals rarely instruct patients about proper insulin injection techniques. This study aimed to assess the practices of insulin injection techniques among patients with diabetes treated and assess the effect of these practices on glycemic control.

Patients and Methods

This cross-sectional study was conducted between November 2020 and February 2021. A random systematic sampling technique was used to recruit study subjects at specialist outpatient clinics. Subjects with type 1 or 2 diabetes mellitus who had been using insulin injections for at least a year were included in this study.

Results

A total of 298 subjects with type 1 diabetes and 553 with type 2 diabetes participated in this study. The mean age of patients with type 1 diabetes was 20.1 ± 10.4 years. The mean age of patients with type 2 diabetes was 58.6 ± 9.5 years. The median type 1 diabetes duration was 6.0 years, and median type 2 diabetes duration was 15.0 years. About 66.8% of patients with type 1 diabetes and 69.4% of patients with type 2 diabetes were rotating insulin injection sites. Almost 36.6% of patients with type 1 diabetes and 50.5% of patients with type 2 diabetes reported using the same insulin needle more than three times. The prevalence of lipohypertrophy was 57.0% among patients with type 1 diabetes and 55.5% among patients with type 2 diabetes. The absence of lipohypertrophy, rotation of insulin injection site, and total daily insulin dose ≤50 units were all independently significantly associated with better glycemic control.

Conclusion

Insulin injection techniques were suboptimal among significant proportion of patients with diabetes in Jordan. Improper insulin injection technique, especially the rotation of injection sites and lipohypertrophy formation, was associated with uncontrolled blood glucose levels. Educational interventions that focus on insulin injection techniques among Jordanian patients with diabetes are strongly recommended.

Nursing a patient with latent autoimmune diabetes in adults with insulin-related lipodystrophy, allergy, and exogenous insulin autoimmune syndrome: A case report

BACKGROUND

Latent autoimmune diabetes in adults (LADA) is a special type of type 1 diabetes mellitus. During the early stages, patients with LADA are treated with oral antidiabetics. However, insulin treatment is still required as islet function gradually declines. Once patients have developed insulin allergy, clinical treatment and nursing care become very challenging.

CASE SUMMARY

Here, we report a case of LADA with insulin-related lipodystrophy, allergy, and exogenous insulin autoimmune syndrome during insulin treatment, thus making it very difficult to effectively control glucose levels with insulin. We attempted subcutaneous injection and an insulin pump to desensitize the patient’s response to insulin, and finally assisted the doctor to select the appropriate insulin treatment for the patient. We describe the management of this patient from a nursing viewpoint.

CONCLUSION

We summarize the nursing experience of a case with complex insulin allergy requiring desensitization treatment. Our approach is very practical and can be applied to similar patients needing insulin desensitization.

LIPODYSTROPHY FREQUENCY ACCORDING TO INSULIN TREATMENT REGIMEN IN TYPE 2 DIABETIC PATIENTS: IS INSULIN INJECTION FREQUENCY MATTERS IN ANALOG INSULIN ERA?

OBJECTIVES

We aimed to determine lipodystrophy frequency according to insulin treatment regimen and insulin injection frequency in type 2 diabetic patients.

METHODS

A total of 345 type 2 diabetic patients under insulin treatment for at least one year were included in this cross-sectional study. Patients were examined for presence of lipodystrophy, insulin injection frequency and dosage. Lipodystrophy was evaluated with visual inspection and palpation of all injection sites. Patients were evaluated into three categories according to daily insulin dose requirement: Group 1= Standard-dose insulin users 0.6 U/kg/day; Group 2= Medium-dose insulin users 0.61-1.9 U/kg/day, Group 3= High-dose insulin users ≥2 U/kg/day.

RESULTS

Lipodystrophy was seen in 28% of the patients. Lipodystrophy was significantly higher in group 3. There was no significant difference between the groups in terms of lipodystrophy size. Duration of insulin treatment, daily total insulin dose, daily insulin dose per weight and number of daily insulin injections were significantly higher in the group with lipodystrophy. Daily injection number of long-acting, rapidly-acting analog and total insulin injections were significantly higher in group 3 than group 1 and 2. Number of daily insulin injections and lipodystrophy frequency were significantly higher in basal-bolus insulin user group. Multivariate analysis showed that insulin injection frequency is the independent risk factor for lipodystrophy.

CONCLUSION

Lipodystrophy is still a clinical problem in patients with high-dose insulin requirement and frequent insulin injections. Reducing daily insulin requirement and daily number of injections should be given priority in the management of patients to prevent the development of lipodystrophy.

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.

DNA Methylation as a Marker of Body Shape in Premenopausal Women

Preferential accumulation of fat in the gluteo-femoral (GF) depot (pear shape) rather than in the abdominal (A) depot (apple shape), protects against the development of metabolic diseases but the underlying molecular mechanism is still unknown. Recent data, including our work, suggest that differential epigenetic marking is associated with regulation of genes attributed to distinct fat distribution. Here, we aimed to compare the genomic DNA methylation signatures between apple and pear-shaped premenopausal women. To investigate the contribution of upper and lower body fat, we used paired samples of A-FAT and GF-FAT, analyzed on the BeadChip Methylation Array and quantified the differentially methylated sites between the 2 groups of women. We found unique DNA methylation patterns within both fat depots that are significantly different depending on the body fat distribution. Around 60% of the body shape specific DNA methylation sites identified in adipose tissue are maintained ex vivo in cultured preadipocytes. As it has been reported before in other cell types, we found only a hand full of genes showing coordinated differential methylation and expression levels. Finally, we determined that more than 50% of the body shape specific DNA methylation sites could also be detected in whole blood derived DNA. These data reveal a strong DNA methylation program associated with adipose tissue distribution with the possibility that a simple blood test could be used as a predictive diagnostic indicator of young women who are at increased risk for progressing to the apple body shape with a higher risk of developing obesity related complications. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT02728635 and https://clinicaltrials.gov/ct2/show/NCT02226640, identifiers NCT02728635 and NCT02226640.

Associations of insulin-induced lipodystrophy in children, adolescents, and young adults with type 1 diabetes mellitus using recombinant human insulin: a cross-sectional study

OBJECTIVE

Insulin-induced lipodystrophy is of two types, lipohypertrophy and lipoatrophy. Lipodystrophy often leads to worsening of glycemic control in type 1 diabetes mellitus. Our objective was to identify the clinical, immunological, and other factor(s) associated with the development of lipodystrophy.

METHODS

In this observational cross-sectional hospital-based study, 95 children, adolescents, and young adults with type 1 diabetes mellitus were observed for the development of lipodystrophy. Injection technique, insulin dose, and glycemic parameters were noted. Serum TNF-α, IL-1β, and anti-insulin antibody levels were measured. Histopathological examination of the lipodystrophic area was done in a small number of people.

RESULTS

Among the participants, 45.2% of participants had lipohypertrophy and 4.2% had lipoatrophy exclusively; 3.1% of participants had coexisting lipohypertrophy and lipoatrophy. Improper injection site rotation technique was more common in participants with lipohypertrophy in comparison to those without lipodystrophy. The age of onset of diabetes, duration of insulin use, and the number of times of needle reuse were not significantly different between the lipohypertrophy and nonlipodystrophy groups. Serum TNF-α, IL-1β, and anti-insulin antibody levels; HbA_1c; rate of hypoglycemia; and body weight-adjusted dose requirement were higher among the participants with lipohypertrophy. On histopathology, scant, or no inflammatory infiltrate was found in lipoatrophic and lipohypertrophic areas, respectively.

CONCLUSION

Improper insulin injection technique and higher levels of proinflammatory cytokines and anti-insulin antibody are associated with lipodystrophy in type 1 diabetes mellitus. HbA_1c and rate of hypoglycemia are higher in people with lipodystrophy.

A meta-analysis and meta-regression on the prevalence of lipohypertrophy in diabetic patients on insulin therapy

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, HbA_1c, 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.

Improved glycemic control in 3,592 adults with type 2 diabetes mellitus initiating a tubeless insulin management system

AIMS

To compare glycemic outcomes in adults with type 2 diabetes mellitus (T2DM) before and 90 days after initiating Omnipod® or Omnipod DASH® Insulin Management Systems.

METHODS

In this retrospective observational study (N = 3,592) change in HbA1c level, total daily dose (TDD) of insulin (n = 3,053), and frequency of self-reported hypoglycemic events (HE, <70 mg/dL, n = 2,922) were assessed overall and by prior treatment modality (multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII)), age group, and baseline HbA1c category.

RESULTS

Change (mean ± SD) in HbA1c was -1.3 ± 1.7% [-14 ± 19 mmol/mol] overall, -1.4 ± 1.7% [-15 ± 19 mmol/mol] for prior MDI users, and -0.9 ± 1.5% [-10 ± 16 mmol/mol] for prior CSII users (p<0.0001). The percentage of patients with HbA1c ≥9% [≥75 mmol/mol] decreased (49% to 19%), and with HbA1c <7% [<53 mmol/mol] increased (10% to 22%) (p<0.0001). Prior therapy, age, and baseline HbA1c category were factors affecting change in HbA1c (p<0.05). Reductions in TDD (overall, -33 ± 52U, p<0.0001) and HE per week (overall, -0.5 ± 2.0, p<0.0001), were seen regardless of prior treatment, age, or baseline HbA1c.

CONCLUSIONS

Omnipod System use was associated with statistically and clinically meaningful reductions in HbA1c, TDD, and HE compared to prior treatments in T2DM.

Subclinical lipohypertrophy--Easily ignored complications of insulin therapy

AIMS

Subclinical lipohypertrophy is a lesion meeting ultrasonic criteria for lipohypertrophy that was not detected by inspection and palpation. Little information is published on subclinical lipohypertrophy among insulin injection people with diabetes. We aimed to investigate the subclinical lipohypertrophy prevalence, risk factors, and the association between subclinical lipohypertrophy and glycemic control.

METHODS

This observational study included 316 people with diabetes who had continuously received insulin therapy for at least one year. We performed ultrasound scanning and clinical examination for evidence of subclinical lipohypertrophy. Demographic characteristics, clinical information, and glycated hemoglobin were measured.

RESULTS

The overall prevalence of subclinical lipohypertrophy was 19.9%. By stepwise logistic regression, higher BMI (OR = 1.44, 95%CI: 1.15-1.81, P = 0.002), incorrect rotation of sites (OR = 3.11, 95%CI: 1.02-9.47, P = 0.046), insulin needle reusage for more than four times (OR = 10.00, 95%CI: 3.23-31.02, P = 0.000) and type 1 diabetes (OR = 6.33, 95%CI: 1.32-30.47, P = 0.021) remained associated with subclinical lipohypertrophy. Subclinical lipohypertrophy demonstrated a significant independent correlation with the nonoptimal glycemic control (OR = 9.97, 95% CI: 3.46-28.75, P = 0.000) when accounting for demographic and diabetes-related parameters.

CONCLUSIONS

Subclinical lipohypertrophy is common among insulin-injecting patients with diabetes and is related to glycemic control deterioration. Ultrasonography may be an ideal adjunct in the evaluation of easily ignored lipohypertrophy lesions, especially where poor glycemic control, incorrect injection behaviors, overweight or obesity are documented.

Injection Technique Education in Patients with Diabetes Injecting Insulin into Areas of Lipohypertrophy: A Randomized Controlled Trial

INTRODUCTION

The aim of this randomized controlled trial was to assess the impact of providing intensive injection technique (IT) education to patients routinely injecting insulin into sites of lipohypertrophy (LH).

METHODS

Between November 2016 and May 2018, insulin-injecting patients with LH treated at Tianjin Metabolism Hospital (a public tertiary medical institution), Tianjin, China, were included in a 6-month prospective randomized controlled trial and randomized into either the intervention (the IT-education group) or the control (control group) arm. The control and IT-education groups were seen by different groups of trained nurses on different clinic days. IT education emphasized moving injections to normal tissue sites, within-and between-site injection rotation, an initial reduction of insulin total daily dose (TDD), and stopping needle reuse. Needles were provided to the IT group, while controls acquired needles in their usual way. Differences in changes in glycated hemoglobin (HbA1c) and insulin TDD were the primary and main secondary endpoints, respectively.

RESULTS

The control (n = 104) and IT-education (N = 106) groups had similar demographic parameters (97% with type 2 diabetes) and baseline IT behavior. HbA1c reduction was similar in the IT-education and control group in the intention-to-treat (ITT) analysis (6-month between-group difference 0.16% [1.7 mmol/mol], 95% confidence interval [CI] - 0.11, 0.43 [- 1.2, 4.7]; p = 0.239) but was significant by the per-protocol (PP) analysis (difference 0.31% [3.4 mmol/mol], 95% CI 0.02, 0.60 [0.2, 6.6]; p = 0.038). Changes in TDD insulin in the IT-education group were approximately - 7 and - 8 IU by the ITT and PP analyses, respectively, versus - 1 IU (nonsignificant) in the controls (both between-group differences p ≤ 0.05). Despite the study design, IT education "contamination" (unplanned adoption of IT-intervention behaviors) was documented in 63 control patients. By post hoc analyses, HbA1c in "contaminated" controls decreased by 0.70% (7.7 mmol/mol) vs. 0.20% (2.2 mmol/mol) in "non-contaminated' patients (p = 0.019) at 6 months.

CONCLUSIONS

Proper IT, including learning to not inject into sites of LH, proper within- and between site rotation, needle reuse reduction, and the use of 4-mm, 32-G needles in Chinese patients injecting into sites of LH enables a safe reduction of TDD insulin while maintaining overall glycemic control.

TRIAL REGISTRATION

Trial registration: ChiCTR-IOR-16009270 in the Chinese Clinical Trials Registry.

A Coloured Pen Needle Education System Improves Insulin Site Rotation Habits: Results of a Randomized Study

INTRODUCTION

Needle reuse and repeated injection of insulin into the same site encourage lipohypertrophy. We explored the potential of coupling a novel pen needle strategy with community pharmacists to improve injection site rotation.

METHODS

Between October 2018 and January 2019, adult insulin users with type 1 or 2 diabetes were enrolled by 16 community pharmacists across 7 Canadian provinces and randomized to their usual pen needles (control) or coloured pen needles packaged with education materials in boxes with reminder sound chips (intervention [mCPN]). A total of 203 individuals completed all requirements of the 30-day study. The primary outcome was a composite of the number of zones injected, the use of new injection zones if the number of zones equaled that at baseline, and the change in size of the injection area from baseline. The pharmacists completed two questionnaires, which provided insights into whether study participation elevated their comfort and confidence in providing injection site rotation counselling.

RESULTS

Compared to the control group, more participants in the mCPN arm improved their site rotation practices (54.1% vs. 33.7%; P = 0.005), 15 more increased the number of injection zones used (P = 0.03), and there was less needle reuse (25% vs. 12% reduction). The pharmacists reported improved knowledge of the consequences of lipohypertrophy and the proportion who were "very comfortable" with pen needle tip selection and use rose from 31.3% pre-study to 93.8% post-study.

CONCLUSION

The coloured pen needles with their education materials are a novel means of encouraging injection site rotation. Community pharmacists represent an untapped resource for improving injection self-care practices.

Insulin-Induced Skin Lipohypertrophy in Type 2 Diabetes: a Multicenter Regional Survey in Southern Italy

INTRODUCTION

Lipohypertrophies (LHs) due to incorrect insulin injection techniques have been described in the literature for decades. Their rate averages 38%, but this is still controversial because of the vast range reported by different publications, most of which fail to describe the selected detection protocol and therefore are not entirely reliable. We still need to identify the real LH rate, and only consistently using a standardized method in a large cohort of insulin-treated (IT) patients make this possible.

METHODS

Our group performed thorough clinical skin examinations on patients suffering from type 2 diabetes mellitus (T2DM): 1247 IT T2DM outpatients were examined according to a standardized protocol, previously published elsewhere, as well as an ultrasound scan of the same skin areas to assess the degree of concordance between the two methods and to evaluate the demographic, clinical, and behavioral risk factors (RF) as well as metabolic consequences of identified LHs.

RESULTS

The concordance between the two methods was 99%. Identified risk factors for LHs were needle reuse, failure to rotate injection sites, and ice-cold insulin injections. High HbA1c values, wide glycemic variability, and longstanding proneness to hypoglycemia with a high rate of ongoing hypoglycemic events proved to be significantly associated with LHs, too; the same applied to cardiovascular and renal complications as well as to living alone and being retired.

CONCLUSIONS

Based on a strict well-structured methodology, our data confirmed what has already been reported in the literature on factors leading to, or associated with, LHs and, for the first time in adults, indicated cryotrauma from ice-cold insulin injections and specific social conditions as factors facilitating LH occurrence. HCPs should therefore plan a yearly clinical examination of all injection sites to improve patient quality of life through better glucose control and a reduced rate of hypoglycemic events.

TRIAL REGISTRATION

Trial registration no. 127-11.01.2019, approved by the Scientific and Ethics Committee of Campania University "Luigi Vanvitelli," Naples, Italy.

The prevalence of lipohypertrophy and its associated factors among Saudi patients with type 2 diabetes mellitus

Objectives

We conducted this study to establish the prevalence and associated risk factors of lipohypertrophy (LH) in patients with type 2 diabetes mellitus (T2DM) who are on insulin therapy in the Kingdom of Saudi Arabia (KSA).

Methods

This multicenter, cross-sectional study was executed at primary care clinics in King Saud University Medical City and Prince Mohammed Bin Abdulaziz Hospital in Riyadh KSA from May 2017 to October 2017. All adult patients over 18 years old with T2DM who had been treated with insulin via either a syringe or pen for at least two years were physically examined for LH.

Results

A 39.7% prevalence of LH was found in our study cohort of which as many as 57.5% patients were found to be in LH grade 1, 33.75% grade 2, and 8.75% grade 3. LH was detected in 68.8% patients who used different sites for every injection and in 63.7% (p = 0.182) of patients who had injected more than 60 units per day (p < 0.,0001). Overall logistic regression analysis showed that the patients who used alcohol swabs were 2.6 times more likely to develop LH. Interestingly, the patients who used more than 60 units of insulin per day were 0.362 times more likely to develop LH.

Conclusions

Lipohypertrophy is a complication common among patients with T2DM in KSA. It is incumbent upon healthcare providers to raise awareness about LH and to provide extensive education about correct insulin administration among patients with T2DM on insulin 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.

Lipohypertrophy in Individuals with Type 2 Diabetes: Prevalence and Risk Factors

Introduction: As well as its negative effect on the subcutaneous tissues, lipohypertrophy has negative effects on clinical data. The purpose of this study was to examine the frequency of lipohypertrophy, risk factors and perceived barriers preventing rotation in individuals with type 2 diabetes.

Methods: This descriptive cross-sectional study was conducted at Diabetes Education Center and Endocrine and Metabolism Clinic of a university hospital and Diabetes Education and Monitoring Center in a private hospital in Turkey between June 2016- April 2017. The inclusion criteria were as follows; undergoing at least one year of insulin therapy, injecting insulin pens or syringes themselves, being over 18 years of age, making regular injection of insulin and being a patient with type 2 diabetes. Introductory information form was used to collect the data. The data were analyzed using descriptive statistics and chi-square analysis with SPSS version 16.0.

Results: Factors influencing lipohypertrophy development were determined as follows; healthcare personnel who provide insulin education, duration of diabetes, the number of injection administered daily, needle length, the number of injection sites, insulin types, injection site rotation and intra-site rotation and needle exchange frequency. In addition, the prevalence of lipohypertrophy was found to be higher in patients with hypoglycemia, unexplained hypoglycemia, and those with high BMI and A1C.

Conclusion: It is recommended that diabetes education should be provided by the diabetes specialist nurses who have diabetes-specific certifications and / or education and who can provide full-time education. Randomized controlled interventional studies investigating how to prevent the lipohypertrophy development are also needed.

Prevalence of lipohypertrophy in insulin-treated diabetes patients: A systematic review and meta-analysis

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.

Basal insulin peglispro: Overview of a novel long-acting insulin with reduced peripheral effect resulting in a hepato-preferential action

Basal insulin peglispro (BIL) is a novel basal insulin with a flat, prolonged activity profile. BIL has been demonstrated in a dog model, in healthy men and in patients with type 1 diabetes (T1D) to have significant hepato-preferential action resulting from reduced peripheral activity. In the IMAGINE-Phase 3 clinical trial program, more than 6000 patients were included, of whom ~3900 received BIL. Of the 7 pivotal IMAGINE trials, 3 studies were double-blinded and 3 were in T1D patients. BIL consistently demonstrated a greater HbA1c reduction, less glycaemic variability and a clinically relevant reduction in the rates of nocturnal hypoglycaemia across comparator [glargine and isophane insulin (NPH)] studies. Trials using basal/bolus regimens had higher rates of total hypoglycaemia with BIL due to higher rates of daytime hypoglycaemia. Severe hypoglycaemia rates were similar to comparator among both patients with T1D or type 2 diabetes (T2D). T1D patients lost weight compared with glargine (GL). Patients with T2D tended to gain less weight with BIL than with glargine. Compared to glargine, BIL was associated with higher liver fat, triglycerides and alanine aminotransferase (ALT) levels, including a higher frequency of elevation of ALT ≥3 times the upper limit of normal, but without severe, acute drug-induced liver injury. Injection site reactions, primarily lipohypertrophy, were more frequent with BIL. In conclusion, BIL demonstrated better glycaemic control with reduced glucose variability and nocturnal hypoglycaemia but higher triglycerides, ALT and liver fat relative to conventional comparator insulin. The hepato-preferential action of BIL with reduced peripheral activity may account for these findings.

Lipodystrophy in Insulin-Treated Subjects and Other Injection-Site Skin Reactions: Are We Sure Everything is Clear?

Physicians and patients have long been aware of skin lesions at the sites of insulin injections, referred to as lipodystrophy that can present as lipoatrophy (LA) or lipohypertrophy (LH). However, the reported prevalence of these different skin lesions varies widely, emphasizing the need for a correct identification method. In this short review we discuss LA and LH and also take into account other skin lesions, such as bruising, as well as different needle injuries, including those associated with the subcutaneous injection of pegvisomant (a drug aimed at counteracting the high levels of growth hormone associated with acromegaly), long-acting exenatide (a glucagon-like peptide-1 receptor agonist), and anti-tumor necrosis factor-alpha biologic agents (used against Crohn's disease). In these latter cases specific studies are warranted to understand the pathophysiological background and possible prevention. However, the most common lesion is still insulin injection site-related LD, so a strong effort has to be made to avoid the confusion generated by previously misleading classifications which were barely able to reliably distinguish between LA and LH.

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.

Safety of the reuse of needles for subcutaneous insulin injection: A systematic review and meta-analysis

OBJECTIVE

Many people with diabetes often reuse disposable needles for subcutaneous insulin injection. We aimed to identify, critically appraise and summarize the available evidence about the safety of this practice.

DESIGN

Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

MEDLINE (via PubMed), CINALH (via EBSCO), SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials and Open Grey were searched from their inception to December 2015, with no language restrictions.

REVIEW METHODS

Epidemiologic and experimental studies assessing adverse effects of reusing needles in people of any age or sex, with or without diabetes, were included. Two reviewers independently assessed the methodological quality of included studies using a multi-design tool.

RESULTS

In total, 25 studies were included. All studies had a high risk of bias and data from only nine studies could be pooled. Five studies showed no association between infection at site of injection and reuse of needles (risk difference=-0.00; 95% confidence interval=-0.12-0.11; P=0.99); heterogeneity between these studies was substantial (I(2)=66%; P=0.02). Five cross-sectional studies showed an association between lipohypertrophy and needle reuse (risk difference=0.16, 95% confidence interval=0.05-0.28, P=0.006); there was strong evidence of heterogeneity between these studies (I(2)=87%; P<0.001). Pooled data of two studies with no evidence of heterogeneity between them showed more perceived pain among reusers (risk difference=0.24; 95% confidence interval=0.06-0.43; P=0.006). Reusing a pen needle or disposable syringe-needle was not associated with worse glycaemic control.

CONCLUSIONS

There is currently no clear scientific evidence to suggest for or against the reuse of needles for subcutaneous insulin injection. This practice is very common among people with diabetes; consequently, further research is necessary to establish its safety.