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Alam A, Dhoundiyal S, Ahmad N, Rao GSNK. Unveiling Diabetes: Categories, Genetics, Diagnostics, Treatments, and Future Horizons. Curr Diabetes Rev 2024; 20:e180823219972. [PMID: 37594107 DOI: 10.2174/1573399820666230818092958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/15/2023] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Diabetes mellitus is a global epidemic affecting millions of individuals worldwide. This comprehensive review aims to provide a thorough understanding of the categorization, disease identity, genetic architecture, diagnosis, and treatment of diabetes. The categorization of diabetes is discussed, with a focus on type 1 and type 2 diabetes, as well as the lesser-known types, type 3 and type 4 diabetes. The geographical variation, age, gender, and ethnic differences in the prevalence of type 1 and type 2 diabetes are explored. The impact of disease identity on disease management and the role of autoimmunity in diabetes are examined. The genetic architecture of diabetes, including the interplay between genotype and phenotype, is discussed to enhance our understanding of the underlying mechanisms. The importance of insulin injection sites and the insulin signalling pathway in diabetes management are highlighted. The diagnostic techniques for diabetes are reviewed, along with advancements for improved differentiation between types. Treatment and management approaches, including medications used in diabetes management are presented. Finally, future perspectives are discussed, emphasizing the need for further research and interventions to address the global burden of diabetes. This review serves as a valuable resource for healthcare professionals, researchers, and policymakers, providing insights to develop targeted strategies for the prevention, diagnosis, and management of this complex disease.
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Affiliation(s)
- Aftab Alam
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
| | - Shivang Dhoundiyal
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
| | - Niyaz Ahmad
- Department of Pharmaceutical Analysis, Green Research Lab, Green Industrial Company, Second Industrial Area, Riyadh 14334, Saudi Arabia
| | - G S N Koteswara Rao
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS, V.L. Mehta Road, Vile Parle (W), Mumbai 400056, India
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Tian T, Aaron RE, Huang J, Yeung AM, Svensson J, Gentile S, Forbes A, Heinemann L, Seley JJ, Kerr D, Klonoff DC. Lipohypertrophy and Insulin: An Update From the Diabetes Technology Society. J Diabetes Sci Technol 2023; 17:1711-1721. [PMID: 37555266 PMCID: PMC10658672 DOI: 10.1177/19322968231187661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Lipohypertrophy is a common skin complication associated with insulin-treated diabetes. The impact of lipohypertrophy as a contributing factor to suboptimal glycemic control, glucose variability, and hypoglycemia is often under-recognized by health care professionals. In a recent Webinar on April 26, 2023, Diabetes Technology Society asked international experts to provide updates on the latest knowledge related to lipohypertrophy for practicing clinicians and educators, researchers, and industries involved in insulin delivery. A recording of the Webinar is freely available on the Diabetes Technology Society Web site (https://www.diabetestechnology.org/).
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Affiliation(s)
- Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | - Jannet Svensson
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sandro Gentile
- Department of Internal Medicine, Campania University “Luigi Vanvitelli,” Naples, Italy
- Diabetes Unit AID Stabia, Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Angus Forbes
- Division of Care in Long-term Conditions, King’s College London, London, UK
| | | | - Jane Jeffrie Seley
- Division of Endocrinology, Diabetes & Metabolism, Weill Cornell Medicine, New York, NY, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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Huang J, Yeung AM, Kerr D, Gentile S, Heinemann L, Al-Sofiani ME, Joseph JI, Seley JJ, Klonoff DC. Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks. Endocr Pract 2023:S1530-891X(23)00386-5. [PMID: 37098370 DOI: 10.1016/j.eprac.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To review the current status of practical knowledge related to insulin-associated lipohypertrophy (LH) - an accumulation of fatty subcutaneous nodules commonly caused by repeated injections and/or infusions of insulin into the same site. METHODS Review of published literature with additional contributions from leading multidisciplinary experts with the emphasis on clinical aspects including pathophysiology, clinical and economic consequences, diagnosis, prevention and treatment. RESULTS LH is the most common dermatologic complication of insulin therapy. Risk factors for the development of lipohypertrophy include repeated delivery of large amounts of insulin into the same location over time, repeated injection trauma to the skin and subcutaneous tissue, and multiple injections using the same needle. Subcutaneous insulin injection in skin areas with lipohypertrophy is associated with reduced pain; however, this problem can interfere with insulin absorption, thereby increasing the likelihood of glucose variability, hypo- and hyperglycemia when a site is changed. Modern visualization technology of the subcutaneous space with ultrasound can demonstrate lipohypertrophy early in the course of its development. CONCLUSIONS The physiological and psychological consequences of developing insulin lipohypertrophy can be prevented and treated with education focusing on insulin injection techniques.
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Affiliation(s)
- Jingtong Huang
- Diabetes Technology Society, Burlingame, California, USA.
| | - Andrea M Yeung
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, California, USA
| | - Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy; NefroCenter Research Network, Torre del Greco, Naples, Italy
| | | | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jeffrey I Joseph
- Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, California, USA; Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
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Barlas T, Yalcin MM, Coskun M, Demirel D, Altinova AE, Toruner FB, Karakoc MA, Yetkin I, Akturk M. Evaluation of Lipohypertrophy in Patients With Type 1 Diabetes Mellitus on Multiple Daily Insulin Injections or Continuous Subcutaneous Insulin Infusion. Endocr Pract 2023; 29:119-126. [PMID: 36423861 DOI: 10.1016/j.eprac.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine lipohypertrophy (LH) in patients with type 1 diabetes mellitus (T1DM) on multiple daily insulin injections (MDII) or continuous subcutaneous insulin infusion (CSII) and to reveal the factors associated with the development and severity of LH. METHODS Sixty-six patients with T1DM treated with MDII (n = 35, 53%) or CSII (n = 31, 47%) for at least 1 year were included. LH localizations were detected with palpation and ultrasonography (USG). RESULTS The LH detection rate with USG was significantly higher than that by palpation in the whole group (P < .001). The LH was detected with USG in 30 (85.7%) patients in the MDII group and 22 (71.0%) patients in the CSII group (P = .144). Advanced LH was detected in 13 (37.1%) of the patients treated with MDII and in 3 (9.7%) of the patients treated with CSII. LH was more severe in the MDII group than in the CSII group (P = .013). Diabetes duration and length of infusion set use were significantly longer and body mass index, hypoglycemia, and complication rates were higher in patients with LH than those in patients without LH (P < .05). A positive correlation was found between LH severity and HbA1C and insulin dose (P < .05, for both). MDII as insulin administration method, incorrect rotation, and a history of ketosis were found to be the most related factors with LH severity in a multiple linear regression analysis (P < .05). CONCLUSION USG might be an effective approach for detecting and evaluating the severity of LH. MDII might cause more severe LH than CSII in patients with T1DM. In this study, LH was found to be associated mostly with incorrect rotation technique and a history of ketosis.
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Affiliation(s)
- Tugba Barlas
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Mehmet Muhittin Yalcin
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Meric Coskun
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Dilek Demirel
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Alev Eroglu Altinova
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Fusun Balos Toruner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Ayhan Karakoc
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ilhan Yetkin
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mujde Akturk
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Pasquarella M, Romano C, Alfrone C, Giordano L, Loiacono F, Capece M, Lamberti R, Strollo F. The Economic Burden of Insulin Injection-Induced Lipohypertophy. Role of Education: The ISTERP-3 Study. Adv Ther 2022; 39:2192-2207. [PMID: 35306633 PMCID: PMC9056437 DOI: 10.1007/s12325-022-02105-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
Abstract
Introduction The history of insulin-induced skin lipohypertrophy (LH) runs parallel to that of insulin's 100 years, and an average of 47% of insulin-treated patients still suffer from it today. The metabolic and economic effects of LH are significant, with hypoglycemia being the most striking. The objective of the study was to perform a 52-week follow-up of 713 insulin-treated patients with type 2 diabetes (T2DM) and LH to detect any differences in the occurrence of hypoglycemic events (HYPOs) and related healthcare costs as well as in LH rates and injection habits between an intensive education intervention group (IG) and control group (CG) provided with a single educational session at the starting point. Methods All participants were trained in accurately self-monitoring blood glucose and recording all HYPOs for 6 months, which allowed baseline recordings before they were randomized into the IG, comprising 395 insulin-treated subjects undergoing repeated, structured multimodal education on correct injection techniques as a longstanding behavioral rehabilitation strategy, and the CG, comprising 318 subjects receiving the same structured, multimodal educational session, but only initially. Results Changes in LH rate and size and in performance were large in the IG and only slight and transient in the CG. A striking difference in the rate of decrease of HYPOs was also apparent between groups. Indeed, estimated costs of health interventions for severe and symptomatic HYPOs, which were on the order of €70,000 and €9300, respectively, in the two groups at baseline decreased by 5.9 times and 13.7 times, respectively, at the end of follow-up in the IG and by only approximately half in the CG. Full details of the changes occurring as a result of intensive education are provided in the text. Conclusions The effect of only initial education in the CG was not significant, thus providing evidence of the virtual worthlessness of a single training session on injection techniques, typical of worldwide daily clinical practice, and easily explaining the extremely high prevalence of LH in insulin-treated patients. Conversely, highly positive effects on LH prevalence and size as well as costs expected from decreased HYPO rate were obtained in the IG. To our knowledge, ours is the first 18-month randomized trial in the field. If our experimental model were to be used as an effective, longstanding behavioral rehabilitation strategy and therefore adapted to real-world settings universally, LH prevalence and costs related to their clinical consequences would be drastically reduced. However, only with a strong, relentless commitment of universities, scientific societies, and patient associations can we achieve this ambitious goal, which would provide great institutional savings and improved quality of life for people with diabetes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02105-5.
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Affiliation(s)
- Sandro Gentile
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Giuseppina Guarino
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Teresa Della Corte
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Polyspecialistic Nephrologic Center CNP Srl, Fratta Maggiore, Italy
| | | | | | | | - Laura Giordano
- Emodialysis Center Srl, Nefrocenter Network, Naples, Italy
| | | | - Maurizio Capece
- Vomero Center Crisci Bersabea & C SNC, Nefrocenter Network, Naples, Italy
| | | | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
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Leto G, Barchetta I, De Candia L, Magotti MG, Cianciullo M, Manti R, Negri C, Cimino V, Dodesini AR, Zerella F, Baratta R. Identification of the Inappropriate Clinical Actions (DON'T) to Improve the Management of Patients with Type 2 Diabetes Failing Basal Insulin Supported Oral Treatment: Results of Survey for a Panel of Diabetes Specialists in Italy. Diabetes Ther 2021; 12:2645-2661. [PMID: 34415563 PMCID: PMC8478995 DOI: 10.1007/s13300-021-01137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/02/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Despite the development of several recommendations, glycemic control in a large proportion of patients with type 2 diabetes, including those treated with insulin, remains suboptimal. This study is aimed to identify a set of actions to promote the reduction of inappropriate clinical practices in type 2 diabetes failing basal insulin supported oral therapy (BOT). METHODS A panel of diabetes specialists was assembled to identify a list of ten corrective actions, "things not to do," for the management of type 2 diabetes: five concerning treatments, procedures and diagnostic tests and five about relationship, communication and information. The Choosing Wisely methodology and approach were the inspiration. RESULTS A total of 73/73 (100%) panelists responded to the survey. Twenty-four actions were proposed. The final list of inappropriate actions deemed most important to improve the management of patients with type 2 diabetes failing BOT were: (1) do not use secretagogues-do not neglect the use of innovative glucose-lowering agents; (2) do not underestimate the risk of lack of hypoglycemia awareness; (3) do not underestimate the benefit of personalization of therapy; (4) do not delay insulin intensification; (5) do not delay modification of the therapeutic regimen. In the area of patient communication, the following actions were identified: (1) do not fail to train in the management of hypoglycemia; (2) do not underestimate whether the patient has understood the modification of therapy; (3) do not prescribe injection therapy without adequately instructing the patient to titrate it; (4) do not ignore the patient's adherence; (5) do not stop listening to the patient and verify learning. CONCLUSION A set of corrective experience-based actions to enact in a timely manner, which can assist physicians in improving clinical outcomes and patients' needs in terms of communications and interaction, is proposed. The list is intended to promote discussions among diabetes specialists to provide high-value diabetes care.
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Affiliation(s)
- Gaetano Leto
- Diabetology Unit, Sapienza University of Rome, Polo Pontino, Santa Maria Goretti Hospital, Latina, Italy.
| | - Ilaria Barchetta
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Maria Grazia Magotti
- Department of Intensive Treatment of Diabetes and its Complications, University Hospital of Parma, Parma, Italy
| | - Marco Cianciullo
- Department of Medicine, Nocera Inferiore Hospital, Salerno, Italy
| | - Roberta Manti
- Diabetology Unit, Santa Croce Hospital of Moncalieri, Turin, Italy
| | - Carlo Negri
- Department of Diabetology and Metabolic Diseases, Hospital of Verona, Verona, Italy
| | - Vincenzo Cimino
- Department of Biomedical and Clinical Sciences L. Sacco Endocrinology and Diabetology, Pio Albergo Trivulzio, Milan, Italy
| | - Alessandro R Dodesini
- Diabetology and Endocrine Diseases Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Zerella
- Diabetology, Metabolic Diseases and Clinical Nutrition, San Pio Rummo Hospital of Benevento, Benevento, Italy
| | - Roberto Baratta
- Endocrinology and Diabetology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Pasquarella M, Romano C, Alfrone C, Giordano L, Loiacono F, Capace M, Lamberti R, Strollo F. The Durability of an Intensive, Structured Education-Based Rehabilitation Protocol for Best Insulin Injection Practice: The ISTERP-2 Study. Diabetes Ther 2021; 12:2557-2569. [PMID: 34383261 PMCID: PMC8385007 DOI: 10.1007/s13300-021-01108-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Studies on the durability of an intensive, structured education protocol on best insulin injection practice are missing for people with type 2 diabetes mellitus (T2DM). The aim of this study was to assess the durability of an intensive, structured education-based rehabilitation protocol on best insulin injection practice in well-trained subjects from our previous intensive, multimedia intervention study registered as the ISTERP-1 study. A total of 158 subjects with T2DM from the well-trained group of the 6-month-long ISTERP-1 study, all of whom had successfully attained lower glucose levels compared to baseline levels with lower daily insulin doses and with less frequent and severe hypoglycemic episodes, participated in the present investigation involving an additional 6-month follow-up period, called the ISTERP-2 study. METHODS Participants were randomized into an intervention group and a control group, depending on whether they were provided or not provided with further education refresher courses for 6 months. At the end of the 6 months, the two groups were compared in terms of injection habits, daily insulin dose requirement, number of severe or symptomatic hypoglycemic events, and glycated hemoglobin (HbA1c) levels. RESULTS Despite being virtually superimposable at baseline, the two groups behaved quite differently during the follow-up. The within-group analysis of observed parameters showed that the subjects in the intervention group maintained and even improved the good behavioral results learned during the ISTERP-1 study by further reducing both the rate of injection technique errors (p < 0.001) and size of lipohypertrophic lesions at injection sites (p < 0.02). Conversely, those in the control group progressively abandoned best practice, except for the use of ice-cold insulin and, consequently, had significantly higher HbA1c levels and daily insulin dose requirements at the end of the follow-up than at baseline (p < 0.05). In addition, as expected from all the above, the rate of hypoglycemic episodes also decreased in the intervention group (p < 0.05), resulting in a significant difference between groups after 6 months (p < 0.02). CONCLUSION Our data provide evidence that intensive, structured education refresher courses have no outstanding durability, so that repeated refresher courses, at least at 6-month intervals, are needed to have positive effects on people with T2DM, contributing not only to prevention but also to long-term rehabilitation. TRIAL REGISTRATION Trial Registration no. 118 bis/15.04.2018.
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Affiliation(s)
- Sandro Gentile
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Giuseppina Guarino
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Teresa Della Corte
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Polispecialistic Nephrological Center CNP Srl, Fratta Maggiore, Italy
| | | | | | | | - Laura Giordano
- Emodialysis Center Srl, Nefrocenter Network, Naples, Italy
| | | | - Maurizio Capace
- Vomero Center Crisci Bersabea & C SNC, Nefrocenter Network, Naples, Italy
| | | | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Pasquarella M, Romano C, Alfrone C, Strollo F. Role of Structured Education in Reducing Lypodistrophy and its Metabolic Complications in Insulin-Treated People with Type 2 Diabetes: A Randomized Multicenter Case-Control Study. Diabetes Ther 2021; 12:1379-1398. [PMID: 33738775 PMCID: PMC8099954 DOI: 10.1007/s13300-021-01006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/15/2021] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION It is essential to use the correct injection technique (IT) to avoid skin complications such as lipohypertrophy (LH), local inflammation, bruising, and consequent repeated unexplained hypoglycemia episodes (hypos) as well as high HbA1c (glycated hemoglobin) levels, glycemic variability (GV), and insulin doses. Structured education plays a prominent role in injection technique improvement. The aim was to assess the ability of structured education to reduce (i) GV and hypos, (ii) HbA1c levels, (iii) insulin daily doses, and (iv) overall healthcare-related costs in outpatients with T2DM who were erroneously injecting insulin into LH. METHODS 318 patients aged 19-75 years who had been diagnosed with T2DM for at least 5 years, were being treated with insulin, were routinely followed by a private network of healthcare centers, and who had easily seen and palpable LH nodules were included in the study. At the beginning of the 6-month run-in period (T-6), all patients were trained to perform structured self-monitoring of blood glucose and to monitor symptomatic and severe hypos (SyHs and SeHs, respectively). After that (at T0), the patients were randomly and equally divided into an intervention group who received appropriate IT education (IG) and a control group (CG), and were followed up for six months (until T+6). Healthcare cost calculations (including resource utilization, loss of productivity, and more) were carried out based on the average NHS reimbursement price list. RESULTS Baseline characteristics were the same for both groups. During follow-up, the intra-LH injection rate for the CG progressively decreased to 59.9% (p < 0.001), a much smaller decrease than seen for the IG (1.9%, p < 0.001). Only the IG presented significant decreases in HbA1c (8.2 ± 1.2% vs. 6.2 ± 0.9%; p < 0.01), GV (247 ± 61 mg/dl vs. 142 ± 31 mg/dl; p < 0.01), insulin requirement (- 20.7%, p < 0.001), and SeH and SyH prevalence (which dropped dramatically from 16.4 to 0.6% and from 83.7 to 7.6%, respectively; p < 0.001). In the IG group only, costs-including those due to the reduced insulin requirement-decreased significantly, especially those relating to SeHs and SyHs, which dropped to €25.8 and €602.5, respectively (p < 0.001). CONCLUSION Within a 6-month observation period, intensive structured education yielded consistently improved metabolic results and led to sharp decreases in the hypo rate and the insulin requirement. These improvements resulted in a parallel drop in overall healthcare costs, representing a tremendous economic advantage for the NHS. These positive results should encourage institutions to resolve the apparently intractable problem of LH by financially incentivizing healthcare teams to provide patients with intensive structured education on proper injection technique. TRIAL REGISTRATION Trial registration no. 118/15.04.2018, approved by the Scientific and Ethics Committee of Campania University "Luigi Vanvitelli," Naples, Italy, and by the institutional review board (IRB Min. no. 9926 dated 05.05.2018).
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Affiliation(s)
- Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy.
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy.
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
| | - Teresa Della Corte
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
| | | | - Carmine Romano
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
| | - Carmelo Alfrone
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
| | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy
- Nefrocenter Research Network and Nyx Start-Up, Naples, Italy
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Romano C, Alfrone C, Lmberti C, Strollo F. Bruising: A Neglected, Though Patient-Relevant Complication of Insulin Injections Coming to Light from a Real-Life Nationwide Survey. Diabetes Ther 2021; 12:1143-1157. [PMID: 33687646 PMCID: PMC7994491 DOI: 10.1007/s13300-021-01026-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/08/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Despite the availability of sophisticated devices and suitable recommendations on how to best perform insulin injections, lipohypertrophy (LH) and bruising (BR) frequently occur as a consequence of improper injection technique. AIM The purpose of this nationwide survey was to check literature-reported LH risk factors or consequences for any association with BR METHOD: This was a cross-sectional, observational, multicenter study based on the identification of skin lesions at all patient-reported insulin injection sites in 790 subjects with diabetes. General and injection habit-related elements were investigated as possible BR risk factors. RESULTS While confirming the close relationship existing between LH and a full series of factors including missed injection site rotation, needle reuse, long-standing insulin treatment, frequent hypoglycemic events (hypos), and great glycemic variability (GV), the observed data could find no such association with BR, which anyhow came with high HbA1c levels, missed injection site rotation, and long-standing insulin treatment. CONCLUSION BR most likely depends on the patient's habit of pressing the injection pen hard onto the skin. Despite being worrisome and affecting quality of life, BR seems to represent a preliminary stage of LH but does not affect the rate of hypos and GV. TRIAL REGISTRATION 207/19.09.2017.
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Affiliation(s)
- Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy.
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy.
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Teresa Della Corte
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Carmine Romano
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | | | - Clelia Lmberti
- Nefrocenter Research Network & Nyx Start-Up, Naples, Italy
| | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy
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