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Lipohypertrophy in insulin injecting patients with diabetes mellitus: an under-recognized barrier for glycemic control

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International Journal of Diabetes in Developing Countries Aims and scope Submit manuscript

Abstract

Background

Lipohypertrophy is the one of the commonest local complications that significantly affects glycemic control in patients of diabetes mellitus on treatment with insulin. Our study aimed at assessing the clinical and ultrasonographic characteristics and risk factors for lipohypertrophy on the abdomen in a cohort of insulin-injecting Indian diabetes patients.

Materials

Eighty-eight consecutive patients with type 1 (15/88) or type 2 diabetes mellitus (73/88) were included in this cross-sectional study conducted over a period of 6 months. The prevalence of lipohypertrophy and associated risk factors was assessed by clinical examination. A novel ultrasonographic characterisation of lipohypertrophy (LH) using a predetermined grading system was performed by two sonologists who were blinded to the underlying clinical findings. Kappa statistics was used to calculate the agreement between the clinical and ultrasound methods of detection of lipohypertrophy.

Results

The prevalence of lipohypertrophy was 68% on clinical examination and 90% on ultrasonography with moderate kappa agreement (60%). The commonest patterns on clinical and ultrasonographic assessment were Grade 2 (palpable and visible − 43%) and nodular hyperechoic subcutaneous dystrophy (33%), respectively. Duration of insulin use, incorrect site rotation, and repeated needle reuse (p < 0.01) were the most important risk factors. The total daily dose of insulin (p = 0.01) and mean Hba1c (p = 0.02) were significantly higher in those with clinically detected lipohypertrophy. The needle length, caliber, the mode of delivery, or regimen of insulin used did not significantly impact development of lipohypertrophy (p = 0.15).

Conclusion

A thorough clinical examination of insulin injection sites is of paramount importance in detecting lipohyperyrophy. Adequate control of risk factors can significantly impact insulin requirements and glycemic control, while ultrasonography can prove to be a novel and sensitive tool to detect abdominal lipohypertrophy in the majority of patients, even when clinical examination is non-contributory.

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References

  1. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes mellitus (UKPDS 33).UK prospective diabetes study (UKPDS) Group. Lancet. 1998;352(9131):837–53.

  2. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–86.

    Article  Google Scholar 

  3. Al Ajlouni M, Abujbara M, Batieha A, Ajlouni K. Prevalence of Lipohypertrophy and associated risk factors in insulin treated patients with Type 2 Diabetes Mellitus. Int J Endocrinol Metab. 2015;13(2).

  4. Vardar B, Kizilci S. Incidence of lipohypertrophyin diabetic patients and a study of influencing factors. Diabetes Res Clin Pract. 2007;77:231–6.

    Article  Google Scholar 

  5. Blanco M, Hernández MT, Straussc KW, Amaya M. Prevalence and risk actors of lipohypertrophyin insulin-injecting patients with diabetes. Diabetes Metab. 2013;39:445–53.

    Article  CAS  Google Scholar 

  6. Ji L, Sun Z, Li Q, et al. Lipohypertrophy in China: prevalence, risk factors, insulin consumption, and clinical impact. Diabetes Technol Ther. 2017;19:61–7.

    Article  CAS  Google Scholar 

  7. Volkova Natalia, Davidenko Ilia, Rudakova and Segida Kristina et al. Ultrasonoraphyof insulin injection sites in diabetic patients: a new method of Lipohypertrophy diagnostic presentation number MON-833.Date of Presentation: 2013.

  8. Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B, et al. Indian Injection technique study: population characteristics and injection practices. Diabetes Ther. 2017;8(3):637–57.

    Article  Google Scholar 

  9. Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B, et al. Indian injection technique study: injecting complications, education, and the health care professional. Diabetes Ther. 2017;8(3):659–72.

    Article  Google Scholar 

  10. Kordonouri O, Lauterborn R, Deiss D. Lipohypertrophy in young patients with type 1 diabetes. Diabetes Care. 2002;25(3):634.

    Article  Google Scholar 

  11. Richardson T, Kerr D. Skin related complications of insulin therapy: epidemiology and emerging management strategies. Am J Clin Dermatol. 2003;4(10):661–7.

    Article  Google Scholar 

  12. Kapeluto J, Paty BW, Chang SD, Eddy C, Vancouver GM, Cetal B. Criteria for the detection of insulin-induced lipohypertrophyusing ultrasonography. Can J Diabetes. 2015;39(6):534.

    Article  Google Scholar 

  13. Perciun R. Ultrasonographic aspects of subcutaneous tissue dystrophies as a result of insulin injections. Med Ultrason. 2010;12(2):104–9.

    PubMed  Google Scholar 

  14. Hambridge K. The management of lipohypertrophy in diabetes care. Br J Nurs. 2007;16(9):520–4.

    Article  Google Scholar 

  15. Hauner H, Stockamp B, Haastert B. Prevalence of lipohypertrophy in insulin-treated diabetic patients and predisposing factors. Exp Clin Endocrinol Diabetes. 1996;104(2):106–10.

    Article  CAS  Google Scholar 

  16. Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide injection technique questionnaire study: injecting complications and role of the professional. Mayo Clin Proc. 2016;91(9):1224–30.

    Article  Google Scholar 

  17. Frid AH, Kerugel G, Grassi G, Halimi S, Hicks D, Hirsch LJ, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91(9):1231–55.

    Article  Google Scholar 

  18. Gibney MA, Arce CH, Byron KJ, Hirsch LJ. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendations. Curr Med Res Opin. 2010;26(6):1519–30.

    Article  CAS  Google Scholar 

  19. Volkova N et al. Ultrasonography of insulin injection sites in diabetic patients: a new method of lipohypertrophy diagnostics. Endocrine reviews. Conference: 95th annual meeting and expo of the Endocrine Society, ENDO. 2013;34(3 Suppl. 1).

  20. Campinos C, Le Floch JP, Petit C, Penfornis A, Winiszewski P, Bordier L, et al. An effective intervention for diabetic lipohypertrophy: results of a randomized, controlled, prospective multicenter study in France. Diabetes Technol Ther. 2017;19(11):623–32.

    Article  CAS  Google Scholar 

  21. Tandon N, Kalra S, Balipohypertrophyara YS, Baruah MP, Chadha M, Chandalia HB, et al. Forum for Injection Technique (FIT), India: The Indian recommendations 2.0, for best practice in Insulin Injection Technique, 2015. Indian J Endocr Metab. 2015;19:317–31.

    Article  Google Scholar 

  22. Garg SK, Rewers AH, Akturk HK. Ever-Increasing Insulin-Requiring Patients Globally. Diabetes Technol Ther. 2018;20(S2):S21–4.

  23. Strauss K, De Gols H, Hannet I, Partanen TM, Frid A. A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Pract Diab Int. 2002;19:71–6.

    Article  Google Scholar 

  24. Martinez L, Consoli SM, Monnier L, Simon D, Wong O, Yomtov B, et al. Studying the Hurdles of Insulin Prescription (SHIP): development, scoring and initial validation of a new self- administered questionnaire. Health Qual Life Outcomes. 2007;5:53.

    Article  Google Scholar 

  25. Cefalu WT, Mathieu C, Davidson J. Patients’ perceptions of subcutaneous insulin in the OPTIMIZE study: a multicenter follow-up study. Diabetes Tech Ther. 2008;10:25–38.

    Article  Google Scholar 

  26. DiMatteo RM, DiNicola DD, editors. Achieving patient compliance. The psychology of medical practitioner’s role. Oxford: Pergamon; 1982. p. 233–56.

    Google Scholar 

  27. Joy SV. Clinical pearls and strategies to optimize patient outcomes. Diabetes Educ. 2008;34:54S–9S.

    Article  Google Scholar 

  28. Seyoum B, Abdulkadir J. Systematic inspection of insulin injection sites for local complications related to incorrect injection technique. Trop Dr. 1996;26:159–61.

    Article  CAS  Google Scholar 

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Acknowledgments

RK and RD researched data and wrote the manuscript, MI and FC helped in patient recruitment, SS wrote the manuscript, PCS and KS contributed to researching the data, MDM and FJ contributed to the discussion and edited the manuscript, HAS researched the data and contributed to the discussion, and TVP and NT reviewed and edited the manuscript. The initial findings of this study has been previously presented in the 44th Annual Conference of Research Society for the Study of Diabetes in India (RSSDI) in 2016 and the abstract of the presentation has been published in the following issue of the journal: Int J Diabetes Dev Ctries. 37, 329–375 (2017). https://doi.org/10.1007/s13410-017-0568-z

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Correspondence to Nihal Thomas.

Ethics declarations

The study was approved by the Institutional review board (IRB Min No 9926 dated 05.02.2016).

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Type 1 or type 2 DM subjects of age 18 years and older injecting insulin subcutaneously on the abdomen for at least 6 months duration were recruited after obtaining a written informed consent.

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Kumar, R., Gupta, R.D., Shetty, S. et al. Lipohypertrophy in insulin injecting patients with diabetes mellitus: an under-recognized barrier for glycemic control. Int J Diabetes Dev Ctries 41, 329–336 (2021). https://doi.org/10.1007/s13410-020-00889-2

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  • DOI: https://doi.org/10.1007/s13410-020-00889-2

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