Insulin-induced lipodystrophy and predisposing factors in children and adolescents with type 1 diabetes mellitus (T1DM) in a tertiary care Egyptian center
Lipohypertrophy in T1DM
Keywords:
Insulin, lipohypertrophy, children, adolescents, prevalence, risk factorsAbstract
Background: Lipodystrophy (LH) is one of the most common complications of subcutaneous insulin injection. Many factors are incriminated in the evolution of LH in children with diabetes type 1 (T1DM). LH may affect insulin absorption in the skin areas involved, resulting in a negative impact on blood glucose levels and glycemic variability. Patients and Methods: We calculated and evaluated the prevalence of LH in relation to possible clinical factors associated with the development of LH in a cohort of children (n =115) with T1DM using insulin pens or syringes and we studied possible predisposing factors including their age, duration of T1DM, injection technique, insulin dose/kg, degree of pain perception, and HbA1c level. Results: In our cross-sectional study, 84% of patients were using pens for insulin injection and 52.2 % of them were rotating the site of injection on daily basis. 27 % did not experience pain during an injection while 6 % had the worst hurt. 49.5 % had clinically detectable LH. Those with LH had higher HbA1c levels and more unexplained hypoglycemic events compared to those without LH (P: 0.058). The hypertrophied site was related to the preferred site of injection which was the arms in 71.9 % of the cases. Children who had LH were older with a longer duration of T1DM, rotating sites of injection less frequently, and were more frequently reusing needles compared to children without LH (P: < 0.05). Conclusion: Improper insulin injection technique, older age, and longer duration of T1DM were associated with LH. Proper education of patients and their parents must include correct injection techniques, rotating injection sites, and minimal reuse of needles.
References
Al Hayek AA, Robert AA, Braham RB, Al Dawish MA. Frequency of Lipohypertrophy and Associated Risk Factors in Young Patients with Type 1 Diabetes: A Cross-Sectional Study. Diabetes Ther. 2016;7(2):259-67. doi: 10.1007/s13300-016-0161-3.
Wang K, Zhang S, Liu C, Chen Y. A meta-analysis and meta-regression on the prevalence of lipohypertrophy in diabetic patients on insulin therapy. Therapies 2021;76: 617–28. doi.org/10.1016/ j.therap.2021.04.002.
Barola A, Tiwari P, Bhansali A, Grover S, Dayal D. Insulin-Related Lipohypertrophy: Lipogenic Action or Tissue Trauma? Front Endocrinol (Lausanne). 2018;9:638. doi: 10.3389/fendo. 2018.00638.
Braham RB, Al Dawish MA. Frequency of lipohypertrophy and associated risk factors in young patients with type 1 diabetes: a cross-sectional study. Diabetes Ther. 2016;7:259–67.doi: 10.1007/ s13300-016-0161.
Conwell LS, Pope E, Artiles AM, Mohanta A, Daneman A, Daneman D. Dermatological complications of continuous subcutaneous insulin infusion in children and adolescents. J Pediatr. 2008; 152(5): 622-8.doi.10.1016/j.jpeds.2007.10.006.
Holstein A, Stege H, Kovacs P. Lipoatrophy associated with the use of insulin analogues: a new case associated with the use of insulin glargine and review of the literature. Expert Opin Drug Saf. 2010; 9(2): 225-31.doi:10.1517714740330903496402.
Fiorenza CG, Chou SH, Mantzoros CS. Lipodystrophy: pathophysiology and advances in treatment. Nat Rev Endocrinol. 2011;7(3):137-50. doi: 10.1038/nrendo.2010.199.
Gupta SS, Gupta KS, Gathe SS, Bamrah P, Gupta SS. Clinical implications of lipohypertrophy among people with type 1 diabetes in India. Diabetes Technol Ther.2018; 20:483–91. doi: 10.1089/ dia. 2018. 0074.
Deng N, Zhang X, Zhao F, Wang Y, He H. Prevalence of lipohypertrophy in insulin-treated diabetes patients: A systematic review and meta-analysis. J Diabetes Investig. 2017;9(3):536–43. doi: 10.1111/ jdi.12742.
Thewjitcharoen Y, Prasartkaew H, Tongsumrit P, et al. Prevalence, Risk Factors, and Clinical Characteristics of Lipodystrophy in Insulin-Treated Patients with Diabetes: An OLH Problem in a New Era of Modern Insulin. Diabetes Metab Syndr Obes. 2020 Nov 26;13:4609-20. doi: 10.2147/ DMSO. S282926.
Chen L, Xing Q, Li J, et al. Injection Technique Education in Patients with Diabetes Injecting Insulin into Areas of Lipohypertrophy: A Randomized Controlled Trial. Diabetes Ther. 2021;12(3):813-26. doi: 10.1007/s13300-021-01013-1.
Blanco M, Hernandez MT, Strauss KW, Amaya M. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013;39(5):445–53. doi: 10.1016/j. diabet.2013. 05.006.
Heinemann L. Insulin absorption from lipodystrophic areas: a (neglected) source of trouble for insulin therapy? J Diabetes Sci Technol. 2010;4(3):750-3. doi: 10.1177/193229681000400332.
Gradel AKJ, Porsgaard T, LykkesfeLHt J, et al. Factors Affecting the Absorption of Subcutaneously Administered Insulin: Effect on Variability. J Diabetes Res. 2018;2018:1205121.doi: 10.1155/2018/ 1205121.
Lombardo F, Bombaci B, Alibrandi A, Visalli G, Salzano G, Passanisi S. The Impact of Insulin-Induced Lipodystrophy on Glycemic Variability in Pediatric Patients with Type 1 Diabetes. Children (Basel). 2022;9 (7):1087. doi: 10.3390/children9071087.
De Coninck C, Frid A, Gaspar R, et al. Results and analysis of the 2008-2009 Insulin Injection Technique Questionnaire survey. J Diabetes. 2010;2(3):168-79.doi:10.1111/j.1753-0407.2010.00077.x.
Tsadik AG, Atey TM, Nedi T, Fantahun B, Feyissa M. Effect of Insulin-Induced Lipodystrophy on Glycemic Control among children and Adolescents with Diabetes in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. J Diabetes Res. 2018;2018:4910962. doi: 10.1155/2018/4910962.
Seyoum B, Abdulkadir J. Systematic inspection of insulin injection sites for local complications related to incorrect injection technique. Trop Doct. 1996; 26:159–61. doi:10.1177/00494 7559602 60 0406.
Garra G, Singer AJ, Domingo A, Thode HC Jr. The Wong-Baker pain FACES scale measures pain, not fear. Pediatr Emerg Care. 2013;29(1):17-20.doi:10.1097/PEC0b13e31827b2299.
Demir G, Er E, Atik Altınok Y, Özen S, Darcan Ş, Gökşen D. Local complications of insulin administration sites and effect on diabetes management. J Clin Nurs. 2022;31(17-18):2530-8. doi: 10. 1111/jocn.16071.
Deeb A, Abdelrahman L, Tomy M, et al. Impact of Insulin Injection and Infusion Routines on Lipohypertrophy and Glycemic Control in Children and Adults with Diabetes. Diabetes Ther. 2019; 10(1):259-67. doi: 10.1007/s13300-018-0561-7.
Al Dawish MA, Robert AA, Braham R, et al. Diabetes mellitus in Saudi Arabia: a review of the recent literature. Curr Diabetes Rev. 2015. doi:10.2174/1573399811666150724095130
Van Munster HE, Van de Sande PM, Voorhoeve PG, van Alfen- van der Velten J. Dermatological complications of insulin therapy in childrenwith type 1 diabetes. Eur Diabetes Nurs. 2015;11:79–84.doi: 10.1002/edn.255.
Kalra S, Hirsch LJ, Frid A, Deeb A, Strauss KW. Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications. Diabetes Ther. 2018;9(6):2291-2302. doi: 10.1007/ s13300-018-0514-1.
Schober E, Rami B. Dermatological side effects and complications of continuous subcutaneous insulin infusion in preschool-age and school-age children. Pediatr Diabetes. 2009;10(3):198-201. doi: 10.1111/j.1399-5448.2008.00477.x.
Bochanen N, Decochez K, Heleu E, et al. Lipohypertrophy Monitoring Study (LIMO): Effect of single use of 4 mm pen needles combined with education on injection site rotation on glycaemic control: Confirmation of an unpleasant truth. Diabet Med. 2022;39(1):e14672. doi: 10.1111/dme.14672.
Gentile S, Guarino G, Giancaterini A, Guida P, Strollo F. A suitable palpation technique allows to identify skin lipohypertrophic lesions in insulin-treated people with diabetes. Springerplus 2016;5:563. doi:10.1186/s40064-016-1978-y.
Bertuzzi F, Meneghini E, Bruschi E, Luzi L, Nichelatti M, Epis O. Ultrasound characterization of insulin induced lipohypertrophy in type 1 diabetes mellitus. J Endocrinol Invest. 2017;40(10):1107–13. doi: 10.1007/s40618-017-0675-1
Sanlioglu AD, Altunbas HA, Balci MK, Griffith TS, Sanlioglu S. Clinical utility of insulin and insulin analogs. Islets. 2013;5(2):67-78. doi: 10.4161/isl.24590.
Chowdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ. 2003;327(7411):383–4. doi: 10.1136/bmj.327.7411.383.
Frid A H, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. WorLHwide injection technique questionnaire study: injecting complications and the role of the professional. Mayo Clinic Proceedings. 2016;91 (9):1224–30. doi: 10.1016/j.mayocp.2016.06.012.
Kalra S, Jena BN, Yeravdekar R. Emotional and Psychological Needs of People with Diabetes. Indian J Endocrinol Metab. 2018;22(5):696-704. doi: 10.4103/ijem.IJEM_579_17.
Borus JS, Laffel L. Adherence challenges in the management of type 1 diabetes in adolescents: prevention and intervention. Curr Opin Pediatr. 2010;22(4):405-11. doi:10.1097/MOP. 0b013 e32833a46a7.
, Hirsch LJ, Strauss KW. The Injection Technique Factor: What You Don't Know or Teach Can Make a Difference. Clin Diabetes. 2019;37(3):227-33. doi: 10.2337/cd18-0076.
Danne T, Phillip M, Buckingham BA, et al. Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes. Pediatr. Diabetes 2018 ;19 (Suppl. S27), 115–35. doi.org/10.1111/pedi.12718.
Radermecker RP, Pierard GE, Scheen AJ. Lipodystrophy reactions to insulin: effects of continuous insulin infusion and new insulin analogs. Am J Clin Dermatol 2007;8:21-8.doi:10.2165/00128071-200708010-00003.
Roper NA, Bilous RW. Resolution of lipohypertrophy following change of short-acting insulin to insulin lispro (Humalog). Diabet Med 1998;15:1063-4.doi:10.1002/(SICI)1096-9136(1998120)15:12<1063:AID-DIA706>3.0.CO;2-V.
Ramos AJ, Farias MA. Human insulin-induced lipoatrophy: a successful treatment with glucocorticoid. Diabetes Care 2006;29:926-7.doi:10.2337/siacare.29.04.06.dc06-0004.
Hardy KJ, Gill GV, Bryson JR. Severe insulin-induced lipohypertrophy successfully treated by liposuction. Diabetes Care. 1993;16(6):929-30.doi:10.2337/siacare.16.6.929.
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