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Title: Insulin-induced lipohypertrophy in adult patient with type 1 diabetes treated with a personal insulin pump : epidemiology, diagnosis, risk factors, effectiveness of educational intervention
Abstract:
Insulin-induced lipohypertrophy (LH) (hypertrophy of subcutaneous tissue) is a prevalent complication of insulin therapy, often resulting in deteriorated glycemic control in affected patients. Several risk factors for its occurrence are known, which include infrequent change of insulin delivery sites, multiple use of the same needle, higher total daily insulin dose, longer needle length, longer duration of insulin therapy, higher BMI, low patient education. Its mechanism is thought to be related to the anabolic local action of insulin in subcutaneous adipose tissue. Data on the prevalence of lipohypertrophy vary considerably from study to study, depending on the characteristics of the study population, as well as the diagnostic method used and the experience of the investigator. Data on type 1 diabetic patients treated with a personal insulin pump (continuous subcutaneous insulin infusion, CSII) are particularly scarce. Ultrasound (US) examination of subcutaneous tissue is considered the gold standard for diagnosis. In recent years, there have also been reports emphasizing that LH diagnosis by ultrasound combined with educational intervention, including recommending avoidance of insulin injections in areas of lipohypertrophy, can improve metabolic control. In the pump therapy patients population, patient education on proper use of infusion sets, supported by ultrasound diagnost ; ics of insulin injection sites, could contribute to improving patients' metabolic compensation. The study presented in this dissertation was carried out in a selected group of young patients with type 1 diabetes using treatment with a personal insulin pump only. The results of the first study show how common LH is - in the study cohort, LH was detected by ultrasound in up to 94.9% of patients, while by physical examination (including visual and palpation evaluation) in 79.7% of patients. The results show that the prevalence of LH is clearly higher in this group than in previous reports including patients with T1DM, and that the presence of LH on the basis of physical examination is significantly underestimated. Most of the patients had so-called subclinical LH changes - visible on ultrasound but elusive on physical examination. The results confirm that ultrasound should be considered the reference method for LH screening in patients with T1DM. The identified risk factors for the number of LH lesions were related to insulin dosage, which is consistent with previous studies. However, we report for the first time that not only insulin dose, but also the ratio of insulin dose per kilogram of body weight was associated with the severity of the number of LH lesions. Greater length of cannula used in infusion sets and higher BMI were also found to be risk factors for advanced LH (acco ; rding to the author's scale that takes into account the number and size of lesions). These factors should be taken into account in LH prevention in daily clinical practice. The results of our second observation add to our knowledge of the behavior of T1DM patients treated with CSII related to their use of insulin infusion sets (IIS). We noted that many patients with T1DM do not follow the recommended rules for IIS use, do not use the optimal site rotation technique, and prolong the interval between IIS changes. As many as one-third of patients who placed IIS in LH regions were aware of this. The educational intervention carried out in this group of patients, which consisted of assessing the LH and re-training patients on the proper use of the IIS, resulted in improved patient compliance, including a reduction in the percentage of patients not using the repetitive IIS rotation method. Many patients admitted that, prior to the training, they were unaware of the possibility of inserting IIS in regions of the body other than those they had used previously, and appreciated gaining information about the location of their LH foci. These results show that it is worthwhile for patients to be continually educated on the proper use of IIS even after many years of T1DM and CSII treatment. In the third study, a structured intervention including ultrasound-based LH assessment combined with t ; raining in the proper use of IIS was shown to result in improved metabolic control of diabetes and a reduction in total daily insulin dose. The intervention resulted in a reduction in HbAic percentage after a median of 22 weeks, which is consistent with previous studies that found better glycemic control resulting from the elimination of insulin injections in LH areas. However, we did not demonstrate that the intervention performed resulted in improved short-term glycemic control parameters - though a limitation of our study was the evaluation based only on glucose meter data and the lack of detailed instructions to patients on the possible reduction in daily insulin requirements after bypassing LH sites. It was also observed that the intervention used resulted in a reduction in daily insulin requirements, which is consistent with previous studies. It was further noted that the percentage of basal insulin dose increased, while the percentage of bolus dose decreased. These findings, together with the evaluation of data from continuous glycemic monitoring systems, may be helpful in establishing future recommendations for initial insulin dose reduction after an educational session on the use of IIS and an examination to localize LH sites (ultimately by ultrasound). Based on our findings, we postulate that a periodic intervention to educate patients on the correct principles of usi ; ng IIS along with ultrasound- based LH assessment should become part of routine care for T1DM patients treated with CSII. The findings from the studies outlined in the dissertation enhance our understanding of insulin-induced LH in T1DM patients undergoing CSII treatment, underscoring the pivotal role of ultrasound in diagnosing this condition. Additionally, these findings shed light on patients' daily routines and practices concerning the use of IIS. The effectiveness of an educational intervention, including a reminder of the principles of IIS use, combined with ultrasound assessment of LH, in improving glycemic control and reducing daily insulin requirements has also been confirmed.
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Rada Dyscypliny Nauki medyczne
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Last modified:
Feb 17, 2025
In our library since:
Feb 17, 2025
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http://dl.cm-uj.krakow.pl:8080/publication/5200
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| Edition name | Date |
|---|---|
| ZB-141641 | Feb 17, 2025 |
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