Challenge in Achieving Target Hba1c in a relatively rare Diabetes complication
MU Haq, G Morrison & PJ Weston
We present a case of 55 years old obese man with type 2 diabetes of 13 years duration, seen in diabetes clinic. His HbA1c had been 810% for about 7 years despite being on maximum doses of sulphonylurea and metformin.
It was decided to start him on 30/70 mixed insulin and Metformin was continued. His HbA1c did not improve despite aggressive insulin titration. His injections became painful as insulin doses increased and resistance was noted on injecting. Hard lumps formed at injection sites and insulin could not be injected at all at some sites. There was no improvement on using different size needles.
Examination revealed pebble like palpable lumps at injection sites. Skin was noted to be tight over the abdominal wall, upper back and thighs.
Investigations: Positive anti-Scl 70 antibody but other connective tissue screening was normal. CT scan-abundant intra-abdominal fat but scanty subcutaneous fat. A skin biopsy showed a thick lesion and confirmed a diagnosis of Scleredema Diabeticorum.
A further attempt with oral hypoglycaemics including rosiglitazone, was unsuccessful (HbA1c 11.1%). CSSI was not tolerated due to pain.
After failure of above attempts to improve HbA1c, it was decided to try needle free injection device. This delivers insulin via high-pressure stream into subcutaneous tissue. This system revolutionised insulin administration for this patient. Seventeen months on and he was injecting 30/70 insulin bd along with metformin 1 g bd. Target HbA1c has been achieved (6.9%) and no problems have been reported.
We have highlighted the need to consider needle free device early in Scleredema diabeticorum to improve glycaemic control and to consider this condition in patients who are having difficulty with injecting insulin.