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Gentile S, Guarino G, Strollo F. Unexpected evolution of a monster case of insulin-induced skin lipohypertrophy. Diabetes Res Clin Pract 2023; 206:110994. [PMID: 37931883 DOI: 10.1016/j.diabres.2023.110994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023]
Abstract
In this journal, in 2020, we published the case of a 74-year-old female outpatient with type-2 diabetes mellitus who self-injected insulin four times a day according to the basal-bolus regimen, with an high glycemic variability and an high rate of severe hypoglycemic episodes. Three years before, we had found two extraordinarily large skin lipohypertrophies, with large underlying fluid collections with high insulin concentration. A long educational and intensive training completely repaired the skin lesions with the disappearance of the subcutaneous insulin reservoirs. Glycemic variability has been reduced dramatically, severe hypoglycemia has almost completely disappeared and the daily dose of insulin has been reduced by 38%. However, this extraordinary, albeit unexpected, result was achieved in five years.
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Affiliation(s)
- S Gentile
- Department of Internal Medicine, Campania University ''Luigi Vanvitelli'', Naples, Italy; Nefrocenter Research Netwofk, Torre del Greco, Italy.
| | - G Guarino
- Department of Internal Medicine, Campania University ''Luigi Vanvitelli'', Naples, Italy; Nefrocenter Research Netwofk, Torre del Greco, Italy.
| | - F Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Ucieklak D, Mrozińska S, Wojnarska A, Małecki MT, Klupa T, Matejko B. Type 1 Diabetes Mellitus and Lipohypertrophy - Impact of the Intervention on Glycemic Control via Patient's Examination and Retraining on Change of Infusion Set. Endocr Pract 2023; 29:174-178. [PMID: 36581082 DOI: 10.1016/j.eprac.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Lipohypertrophy (LH) is a common complication of insulin therapy in type 1 diabetes mellitus (T1DM). We examined whether an intervention consisting of LH assessment and retraining on insulin infusion set use improves glycemic control on subcutaneous insulin infusion (CSII) in patients with T1DM. METHODS The intervention was conducted in 79 consecutive patients with T1DM. Data on glucose levels, glycated hemoglobin (HbA1c), and insulin doses were collected at baseline and after a median of 22 weeks (20-31.75 weeks). RESULTS A total of 46 patients with T1DM (23 [50%] women) participating in the follow-up were characterized by a median age of 29 years (25-33.8 years), body mass index of 24.6 ± 3.3 kg/m2, T1DM duration of 16.5 years (8.3-20 years), and subcutaneous insulin infusion duration of 7 years (4-10.8 years). Patients' median HbA1c fell from 7.4% (6.7%-8.2%) to 7.05% (6.4%-7.6%) (P < .001), daily insulin dose/kg decreased (0.7 ± 0.20 vs 0.68 ± 0.15 IU/kg; P = .017) together with the total daily insulin dose (50.3 [40.5-62.7] vs 47.6 [39.8-62.1] IU; P = .019]. Furthermore, the percentage of basal insulin dose increased (43.0% [36-50] vs 44.0% [39.0-50.0]; P = .010], whereas the percentage of bolus dose decreased (57% [50-64] vs 56% [50-61], P = .010). CONCLUSIONS The structured LH-related intervention in patients with T1DM on insulin pumps resulted in better glycemic control and a decrease in total daily insulin dose.
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Affiliation(s)
- Damian Ucieklak
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Sandra Mrozińska
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland; Department of Pathophysiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Aleksandra Wojnarska
- Department of Metabolic Diseases, University Hospital, Krakow, Poland; Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T Małecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Bartłomiej Matejko
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland.
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Honjo S, Koshii Y, Tozaka S, Tateno H, Keidai Y, Seno Y, Iwasaki Y, Iwasaki K, Ayano S, Hamasaki A. Exploratory study on glycemic control improvement for patients with diabetes mellitus by appropriate re-education on insulin self-injection technique during COVID-19 pandemic. Diabetes Res Clin Pract 2023; 195:110192. [PMID: 36544290 PMCID: PMC9701578 DOI: 10.1016/j.diabres.2022.110192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/15/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
AIMS To conduct a study on glycemic control improvement by appropriate re-education on the self-injection technique (SIT) in patients with diabetes mellitus undergoing insulin therapy. METHODS Patients who received appropriate SIT and were treated with insulin for more than a year were re-educated. For the observation period of six months, the subjects' SIT was checked, and hemoglobin A1c (HbA1c) levels were measured at each visit. HbA1c levels, insulin doses, and behavioral changes in SIT were investigated at baseline and at the end of the observation period. RESULTS In the per-protocol set population, the HbA1c level decreased by 0.2 % (2.0 mmol/mol) on average, showing a significant difference (p = 0.009). No significant difference was observed in the proportion of subjects with decreased HbA1c levels, changes in total daily insulin doses, or blood glucose levels. Four of the six SIT items covered by re-education were improved. CONCLUSIONS Providing re-education on insulin SIT was considered effective in reducing HbA1c levels and improving adherence to proper SIT.
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Affiliation(s)
- Sachiko Honjo
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Yukako Koshii
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Shusaku Tozaka
- Nippon Becton Dickinson Company, Limited, 15-1, Akasaka 4-chome, Minato-ku, Tokyo 107-0052, Japan.
| | - Hiroko Tateno
- Nippon Becton Dickinson Company, Limited, 15-1, Akasaka 4-chome, Minato-ku, Tokyo 107-0052, Japan.
| | - Yamato Keidai
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Yohei Seno
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Yorihiro Iwasaki
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Kanako Iwasaki
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Shiho Ayano
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
| | - Akihiro Hamasaki
- Department of Diabetes and Endocrinology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-Kofukai, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan.
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Pasquarella M, Romano C, Alfarone C, Giordano L, Loiacono F, Capece M, Lamberti R, Strollo F. Why Do So Many People with Type 2 Diabetes Who Take Insulin Have Lipohypertrophy? Fate or Educational Deficiencies? Diabetes Ther 2023; 14:179-191. [PMID: 36472805 PMCID: PMC9735184 DOI: 10.1007/s13300-022-01341-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Cutaneous lipohypertrophy (LH) is a thickened, "rubbery" lesion in the subcutaneous tissue following multiple injections performed at the same site, i.e., an incorrect injection technique. It is widespread, averaging 47% of insulin patients worldwide, and has severe direct and indirect consequences. Direct consequences consist mainly of poor metabolic control and frequent hypoglycemic events (HYPOs), and indirect ones of markedly increased healthcare costs related to hospital access due to acute events and long-term disease complications. This observation also holds for Italy, despite the National Health System organization expecting every patient with diabetes to undergo a series of visits by different care team members, each performing a specific treatment/education task. Indeed, the recent literature points to poor awareness of LH relevance and metabolic consequences among doctors from general and diabetic hospital wards, with educational deficiencies on correct injection practice in nurses too. The aim was to establish if, to what extent, and by whom they had received training on correct insulin injection techniques, and how many initially received notions had persisted over time. METHODS We investigated the possible causes of such a failure from the point of view of 1160 insulin-requiring subjects with type 2 diabetes (T2DM), reporting for the first time to specialized diabetic structures through a validated questionnaire and, in the same patients, we searched for LH by inspection/palpation according to international guidelines, further confirmed by ultrasound scans. We then analyzed differences in education and injecting behavior between subjects classified as LH+ or LH- depending on the presence or absence of LH lesions. RESULTS We documented significant educational gaps, with 50% of patients failing to refer to healthcare professionals and relying on their peers with diabetes, thought to be more experienced in 15% of the cases. Seventy-five percent of LH- patients received education from healthcare providers, while 90% of LH+ learned from another patient or could not remember how they knew, and 68% of LH+ versus 52% of LH- (p < 0.01) patients had failed to receive training on injection techniques by healthcare providers. All of this enabled the most disabling features of diabetes from the very beginning of the disease history. CONCLUSIONS This study documents, from the patients' point of view, that educational gaps are significant and that, even in initially trained subjects, education on correct injection techniques has a fleeting effect if not regularly recalled. Therefore, to rehabilitate LH+ patients as soon as possible and prevent LH- patients from inadvertently slipping into the other group, there is an urgent need to educate doctors and nurses repeatedly on the importance of correctly injecting insulin to improve patients' knowledge and skills.
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Affiliation(s)
- Sandro Gentile
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Giuseppina Guarino
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Teresa Della Corte
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Giampiero Marino
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, 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 and 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, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ichikawa M, Akiyama T, Tsujimoto Y, Anan K, Yamakawa T, Terauchi Y. Efficacy of education on injection technique for patients diagnosed with diabetes with lipohypertrophy: systematic review and meta-analysis. BMJ Open 2022; 12:e055529. [PMID: 35256444 PMCID: PMC8905878 DOI: 10.1136/bmjopen-2021-055529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the efficacy of providing education on injection technique to patients with diabetes with lipohypertrophy (LH). DESIGN We conducted a systematic review and meta-analysis. METHODS We included patients with diabetes who use insulin and have LH, and excluded patients without LH. We performed a literature search on CENTRAL, MEDLINE, EMBASE, ICTRP and ClinicalTrials.gov in November 2021 for randomised controlled trials (RCTs). We used the revised Cochrane Risk of Bias 2 tool to evaluate the risk of bias in each outcome in each study. We then pooled the data using a random-effects model and evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. OUTCOME MEASURES The primary endpoints were change in total daily dose (TDD) of insulin, change in HbA1c levels and prevalence of hypoglycaemia. RESULTS We screened 580 records and included three RCTs (637 participants) in the meta-analysis. Education on injection technique may slightly increase the change of TDD of insulin (three studies, 637 participants: mean difference (MD) -6.26; 95% CI -9.42 to -3.10; p<0.001; I2=38%; low certainty of evidence) and may have little to no effect on change in HbA1c but the evidence is very uncertain compared with that in the control group (three studies, 637 participants: MD -0.59; 95% CI -1.71 to 0.54; p=0.31; I2=98%; very low certainty of evidence). Providing education about injection technique may have little to no effect on the prevalence of hypoglycaemia (three studies, 637 participants: risk ratio 0.44; 95% CI 0.06 to 3.13; p=0.41; I2=90%; very low certainty of evidence). CONCLUSIONS The present meta-analysis suggests that injection technique education may result in a slight reduction in the TDD of insulin. However, the effect of education on HbA1c, hypoglycaemia and cured LH is uncertain. PROTOCOL REGISTRATION DOI: dx.doi.org/10.17504/protocols.io.btiinkce.
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Affiliation(s)
- Masahiro Ichikawa
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama, Japan
| | - Tomoaki Akiyama
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama, Japan
| | - Yasushi Tsujimoto
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
| | - Keisuke Anan
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Tadashi Yamakawa
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University School of Medicine, Yokohama, Japan
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Shen M, Shi Y, Zheng S, Fan H, Xu J, Yang T. A Systematic Survey of Physicians' Insights Into Lipohypertrophy. Front Public Health 2021; 9:738179. [PMID: 34888280 PMCID: PMC8650682 DOI: 10.3389/fpubh.2021.738179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022] Open
Abstract
Background: It is important that physicians be aware of LH. We designed a questionnaire to determine physician awareness, knowledge, and behaviors regarding LH in clinical practice. Participants: A total of 499 questionnaires were completed by physicians in hospitals from 13 cities in Jiangsu Province, China. Key Results: Compared with physicians at tertiary hospitals, significantly fewer physicians at primary hospitals reported awareness of LH and its screening methods. The proportion of resident physicians aware of LH was significantly lower than the proportion of senior physicians. The proportion of physicians who could identify all LH risk factors among the low-GDP group was significantly higher than the high-GDP group. Only 38.7% of doctors could successfully identify all the hazards associated with LH, but more doctors in tertiary hospitals were able to do so compared to those in secondary and primary hospitals. Compared with tertiary hospitals, the proportions of primary and secondary hospitals with management processes were significantly lower. The proportion of doctors who educated patients regarding LH prevention and treatment in primary hospitals was markedly lower than in tertiary hospitals. Conclusions: Overall, physicians have an inadequate understanding of LH, especially in primary hospitals.
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Affiliation(s)
- Min Shen
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yun Shi
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuai Zheng
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongqi Fan
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jingjing Xu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Yang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Di Bartolo P, Eckel RH, Strollo F, Gentile S. Hundred-year experience with insulin and lipohypertrophy: An unresolved issue. Diabetes Res Clin Pract 2021; 178:108924. [PMID: 34153354 DOI: 10.1016/j.diabres.2021.108924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
In the article recently published in Diab Res Clin Pract (1), we described one of the most exciting paths in the history of medicine from the perspective of diabetologists and people with type 1 diabetes. Such a history lasted 100 years, from the discovery of insulin to the most technologically advanced technologies aimed at making treatment as close to physiology and user-friendly as possible. Indeed, we are luckier than others because, by living in Italy and the USA, respectively, we have access to miniaturized and computerized insulin delivery systems, but this is not the case worldwide. Due to that, while receiving many favorable comments from colleagues and friends, we were encouraged to further expand on the issue and go deeper into insulin injection technique.
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Affiliation(s)
- Paolo Di Bartolo
- Diabetes Clinic of Ravenna, Ravenna Dept. of Internal Medicine, Romagna Local Health Authority, Italy
| | - Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes, Division of Cardiology, University of Colorado Anschutz Medical Campus, United States
| | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
| | - Sandro Gentile
- Department of Experimental and Clinical Medicine, Campania University "Luigi Vanvitelli", and Nefrocenter Research, Naples, Italy
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Gentile S, Satta E, Strollo F, Guarino G, Romano C, Della Corte T, Alfarone C. Insulin-induced skin lipohypertrophies: A neglected cause of hypoglycemia in dialysed individuals with diabetes. Diabetes Metab Syndr 2021; 15:102145. [PMID: 34186346 DOI: 10.1016/j.dsx.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetes mellitus (DM) is the leading cause of end-stage renal disease and 50% of dialysis patients are insulin-treated. AIM to search for unexplained hypoglycemia (HYPO). METHODS identify a possible cause of HYPO due to altered insulin absorption. RESULTS insulin injected into subcutaneous lipo-hypertrophy (LH) nodules leads to unpredictable HYPOS. CONCLUSION looking for LH systematically and training patients to the best injection technique are new challenges for nephrologists to reduce HYPO and emergency hospitalization rates, thus sparing healthcare resources and improving the quality of life of insulin-treated dialysis patients.
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Affiliation(s)
- Sandro Gentile
- Nefrocenter Research Network & Nyx Innovative Research Start-Up, Naples, Italy; Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Ersilia Satta
- Nefrocenter Research Network & Nyx Innovative Research Start-Up, Naples, Italy; Multi-specialty Nephrology Center (CNP) SrL, Frattamaggiore, Italy
| | - Felice Strollo
- Nefrocenter Research Network & Nyx Innovative Research Start-Up, Naples, Italy; Endocrinology and Diabetes, San Raffaele Termini Institute, Rome, Italy
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy
| | - Carmine Romano
- Nefrocenter Research Network & Nyx Innovative Research Start-Up, Naples, Italy
| | - Teresa Della Corte
- Nefrocenter Research Network & Nyx Innovative Research Start-Up, Naples, Italy; Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy.
| | - Carmelo Alfarone
- Nefrocenter Research Network & Nyx Innovative Research Start-Up, Naples, Italy
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