|
 
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| CASE REPORT |
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| Year : 2022 | Volume
: 13
| Issue : 2 | Page : 184-186 |
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A case of regression of insulin lipohypertrophy with correct injection technique
Dewark Sharma
Rupnath Brahma Civil Hospital, Kokrajhar, Assam, India
| Date of Submission | 11-Feb-2022 |
| Date of Decision | 07-Mar-2022 |
| Date of Acceptance | 12-Mar-2022 |
| Date of Web Publication | 21-Jul-2022 |
Correspondence Address:
Dr. Dewark Sharma
C/o Sanjay Sharma, VPO: Fakiragram, Kokrajhar 783345, Assam
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_18_22
Lipohypertrophy of the injection site is a common and often-neglected complication of treatment with insulin. It causes unpredictable absorption of the drug, leading to higher glycemic variability. Using the correct injection technique, the lesion may be reversed. Here, we present the case of a patient with type 1 diabetes, whose lipohypertrophy regressed over time. Along with this, the patient also attained better glycemic control and freedom from diabetic ketoacidosis. Keywords: Injection technique, insulin, lipohypertrophy
How to cite this article:
Sharma D. A case of regression of insulin lipohypertrophy with correct injection technique. J Diabetol 2022;13:184-6 |
| Key Messages | |  |
This case report highlights how a simple intervention was able to help the patient achieve better glycemic control through the treatment of insulin-related lipohypertrophy.
| Introduction | | |
The job of a physician is to protect the patient not only from the complications of a disease, but also from the complications of treatment. Insulin-related lipohypertrophy is one such complication, which leads to multiple adverse outcomes. With the aid of training regarding the correct injection technique, the condition may be successfully treated.
| Case History | | |
A 12-year-old patient with type 1 diabetes since four years presented in a state of diabetic ketoacidosis, which improved with conservative management. He was on a twice-daily regimen of premixed insulin since diagnosis, administered with a vial and syringe, with a needle size of 4 mm. His body mass index (BMI) was 16.67 kg/m2. During physical examination, the physician noticed two lipohypertrophic lesions on his abdomen. The patient told us that these were the sites where he usually injected his insulin; this history established a diagnosis of insulin-related lipohypertrophy. He preferred injecting insulin at these sites because it was less painful, and he had been using the same insulin needle for up to 15 injections. He told us that frequent episodes of hypoglycemia reduced his motivation for treatment. There was a history of three previous episodes of diabetic ketoacidosis.
At the time of discharge, the correct methods of insulin administration were explained to him and his mother. The patient was encouraged to self-administer his injection, and to take his mother’s help if necessary. He was advised not to use a single needle for more than four pricks, and to keep rotating his site of injection. A basal-bolus regimen was considered suitable for him, but he was unwilling to administer four pricks a day. Hence, he was put on a night dose of glargine and two bolus doses of glulisine before breakfast and dinner. He was prescribed insulin pens with a needle size of 4 mm.
When reviewed after one month, he expressed a strong desire to revert to two pricks a day of premixed insulin regimen, a concession that the doctor allowed. The patient was then lost to follow-up for 8 months. Fortunately, an outreach clinic was started at his hometown. The patient was contacted and asked to come in for a review. His glycemic profile had worsened, but he had not developed any further episodes of hypoglycemia or ketoacidosis. This time, he agreed to take a basal-plus regimen with two bolus shots. This led to a remarkable improvement in his glycemic profile.
Over the next months, HbA1c was consistently less than 9, hypoglycemic episodes were infrequent, and the patient did not develop any episodes of ketoacidosis. Using the correct insulin injection technique, his lipohypertrophic areas regressed to.
| Discussion | | |
Repeated insulin injections at the same site lead to lipogenesis by virtue of the hormone’s anabolic action, manifested as tissue hypertrophy.[1] Using the same needle for multiple injections leads to tissue trauma, which is also a contributory factor.[1] By virtue of their faster absorption, the rapid-acting analogs may minimize the tissue exposure to insulin. Hence, they are associated with a lower prevalence of lipohypertrophy compared with regular insulin and conventional premixed insulin.[2]
Depending on the appearance of the lesion, lipohypertrophy may be graded on a scale of 0 to 3 signifying no change, visible hypertrophy of fat tissue but palpably normal consistency, and massive thickening of fat tissue with higher consistency and lipoatrophy, respectively.[3]
The lesion is often painless and hence the patient prefers to administer the injection at this site. Since the insulin administered at the lipohypertrophic area may not be fully absorbed, it leads to poor glycemic control and high glycemic variability.[1],[2],[4],[5] Lipohypertrophy has been associated with an increased risk of both acute and chronic complications of diabetes.[2],[4],[6],[7] By virtue of its various implications, lipohypertrophy leads to increased economic burden on the patient.[7]
Skin ultrasound scans are regarded as the gold standard for the detection of lipohypertrophy.[8],[9] With proper training provided to health-care providers, simple inspection and palpation can exhibit a sensitivity that is comparable to that of ultrasound scans.[8]
Correct injection technique is the only therapeutic intervention that can help in the prevention and regression of lipohypertrophy.[1] Ideally, an insulin needle should not be reused.[1],[8] However, patients may continue to reuse them for financial reasons. Even though such patients are not mandatorily subjected to stopping this practice, they should be properly counseled.[9] The anterior abdomen (away from the umbilicus), upper arms, anterior thigh, and buttocks are the commonly recommended sites for injection. Patients can divide the injection sites into quadrants and halves; they can use each quadrant/half for one week before moving into the others[1] A gap of 1–2 cm (1 finger breadth) between the sites of injection is recommended, and patients should be asked not to inject into existing lesions. The use of needles that are longer than 4–5 mm should be avoided.[1]
| Conclusion | | |
Lipohypertrophy is easy to detect but is commonly missed. The patient must be made aware of this condition before being started on insulin. This needs to be reinforced through a regular examination in the clinic. With a few simple interventions, the quality of life of patients can be markedly improved.
Financial support and sponsorship
None
Conflicts of interest
None
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.  | Table 1: Treatment of the patient over time (blank chambers indicate data not available/ investigation not done)
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| References | | |
| 1. | Tandon N, Kalra S, Balhara YP, 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 Endocrinol Metab 2015;19:317-31.  |
| 2. | Barola A, Tiwari P, Bhansali A, Grover S, Dayal D Insulin-related lipohypertrophy: Lipogenic action or tissue trauma? Front Endocrinol (Lausanne) 2018;9:638. |
| 3. | Kordonouri O, Lauterborn R, Deiss D Lipohypertrophy in young patients with type 1 diabetes. Diabetes Care 2002;25:634. |
| 4. | Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW Worldwide injection technique questionnaire study: Injecting complications and the role of the professional. Mayo Clin Proc 2016;91:1224-30. |
| 5. | Gentile S, Agrusta M, Guarino G, Carbone L, Cavallaro V, Carucci I, et al. Metabolic consequences of incorrect insulin administration techniques in aging subjects with diabetes. Acta Diabetol 2011;48:121-5. |
| 6. | Barola A, Tiwari P, Bhansali A Insulin-mediated lipohypertrophy: An uncommon cause of diabetic ketoacidosis. BMJ Case Rep 2017;2017:bcr2017220387. |
| 7. | 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;9:536-43. |
| 8. | Gentile S, Guarino G, Giancaterini A, Guida P, Strollo F; AMD-OSDI Italian Injection Technique Study Group. A suitable palpation technique allows to identify skin lipohypertrophic lesions in insulin-treated people with diabetes. Springerplus 2016;5:563. |
| 9. | Silver B, Ramaiya K, Andrew SB, Fredrick O, Bajaj S, Kalra S, et al. Eadsg guidelines: Insulin therapy in diabetes. Diabetes Ther 2018;9:449-92. |
[Figure 1]
[Table 1]
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