An Effective Intervention for Diabetic Lipohypertrophy: Results of a Randomized, Controlled, Prospective Multicenter Study in France

Campinos, Catherine; Floch, Jean-Pierre Le; Petit, Catherine; Penfornis, A.; Winiszewski, Patrice; Bordier, L.; Lepage, Marie L.; Fermon, C.; Louis, Jacques; Almain, Catherine; Morel, Didier; Hirsch, Laurence; Strauss, Kenneth

doi:10.1089/dia.2017.0165

Cited by 42 publications

(57 citation statements)

References 23 publications

(18 reference statements)

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“…Clearly there is much more that can be done to raise awareness of LH as well as intervene by teaching proper site rotation and limiting needle reuse [25]. Awareness also needs to be raised concerning proper disposal of used (potentially infectious) needles.…”

Section: Discussionmentioning

confidence: 99%

Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

et al. 2018

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IntroductionThe 2015 Insulin Injection Technique Questionnaire survey involving 13,289 patients included 898 (6.8%) patients in the pediatric age range (≤ 18 years).MethodsThe younger patients included in the questionnaire survey were grouped according to age: Group 1 (G1), 0–6 years, n = 85; Group 2(G2), 7–13, n = 423; Group 3 (G3), 14–18, n = 390. The injection technique was evaluated by means of a questionnaire and nurse assessment.ResultsNurses found lipohypertrophy at injection sites in 41.3, 45.2, and 47.3% of patients in G1, G2, and G3, respectively. Unexpected hypoglycemia was common, ranging from 23.8 to 48.1% of patients, and glucose variability was even more common (61.0% in G1, 45.9% in G2, and 52.5% in G3); both conditions were associated with lipohypertrophy. While increasing numbers of patients were using the recommended 4-mm needles, large percentages still used longer ones (33.3% in G1, 45.9% in G2, and 61.5% in G3). The reuse of needles was also common, ranging from 21.1 to 32.5% in the three age groups. Excessive reuse, defined as using a single needle more than five times, was reported by 9.4–21.8% of patients in the three age group. The percentages of patients who had not received any injection training in the last 12 months ranged from 21.2 to 26.8% in the three groups.ConclusionImplications of our study are as follows: (1) pediatric patients should use 4-mm pen needles or 6-mm syringes (inserted at a 45° angle); (2) patients aged ≤ 6 years should always inject into a raised skin fold regardless of which device is used; (3) all patients should rotate sites and use needles only once to avoid lipohypertrophy.FundingBecton–Dickinson (BD) diabetes care.

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Section: Discussionmentioning

confidence: 99%

Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

et al. 2018

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“…Most studies of LH report that affected patients have a significantly higher insulin TDD than patients without LH ( 2 , 4 , 63 , 64 ). Higher insulin doses related to LH lead to substantial increases in direct costs for individual patients or payers.…”

Section: Local Complicationsmentioning

confidence: 99%

The Injection Technique Factor: What You Don’t Know or Teach Can Make a Difference

Hirsch

Strauss²

2019

Clinical Diabetes

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IN BRIEF To be consistently effective, insulin must be delivered into subcutaneous tissue. If insulin is delivered intramuscularly, its uptake and action become variably faster, leading to suboptimal, inconsistent glucose control. The best strategy to avoid intramuscular injection is to use the shortest needles available. Injection sites should be rotated systematically to prevent lipohypertrophy, which also substantially affects insulin uptake and action. New evidence-based insulin delivery recommendations are available, and awareness of them should lead to more effective use of insulin therapy, improved clinical outcomes, and considerable cost savings.

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“…In a controlled, prospective, multicenter study in French patients [79], all of whom had LH, the intervention consisted of instructions to move injections to non-LH areas, to correctly rotate within injection sites, to forego needle reuse, and to switch to 4-mm needles in order to facilitate correct rotation without increased IM injections. These patients were also given intensive education on the injection recommendations as summarized in this chapter.…”

Section: Lipohypertrophymentioning

confidence: 99%

“…The available data from intervention trials in patients with insulin-related LH show consistently positive outcomes. However, there are limitations to each trial-some were not randomized; in another, the control group received meaningful parts of the educational intervention [79]. Results of one or more ongoing randomized clinical trials should provide more definitive answers to the impact of injection technique training in the near future.…”

Section: Lipohypertrophymentioning

confidence: 99%

Optimal Insulin Delivery

Frid¹,

Hirsch²,

Strauss³

2019

Ultimate Guide to Insulin

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Insulin therapy is only effective if it is delivered into the right tissue in the right way. Exogenous insulin is intended for the subcutaneous (SC) tissue, not the muscle or skin. If delivered into the latter, its absorption (pharmacokinetics (PK)) and action (pharmacodynamics (PD)) are unpredictable, which often leads to poor glucose control. Correct insulin therapy begins with matching the insulin to the site used. Typically, four sites are used for insulin injection or infusion: the abdomen lateral to the umbilicus all the way to the flanks, the anterior lateral upper half of the thigh, the deltoid region of the arm, and the upper outer quadrant of the buttocks. Regular insulin and neutral protamine Hagedorn (NPH) are both absorbed more rapidly from the arm and abdominal sites and more slowly from the thigh and buttocks. The newer insulin analogs, both rapid-and slow-acting, do not appear to be influenced by the site used for injection. In order to avoid intramuscular (IM) injections, patients should use the shortest needles currently available (the 4-mm pen needle and the 6-mm syringe needle). Very young children should raise a skin fold and inject into it even when using the 4-mm needle. Giving injections with the 6-mm needle at a 45° angle converts this needle into the equivalent of the 4 mm. Injection sites should be rigorously rotated, with the new injection being approximately 1 cm from previous injections. This measure helps prevent the most common complication of injection therapy, lipohypertrophy (LH). Injecting into LH leads to unstable PK and PD and deregulated glucose control, manifested as unexpected hypoglycemia, glycemic variability, and elevated HbA1c values. Comprehensive insulin deliver recommendations have recently been published.

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An Effective Intervention for Diabetic Lipohypertrophy: Results of a Randomized, Controlled, Prospective Multicenter Study in France

Cited by 42 publications

References 23 publications

Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

The Injection Technique Factor: What You Don’t Know or Teach Can Make a Difference

Optimal Insulin Delivery

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