Insulin-induced lipohypertrophy, past, present and future: are we losing the battle?
Gideon Mlawa1,2, Dauda Balami3, Sandeep Deshmukh1, Maureen Croft2, Charles Bodmer2 & Mayank Patel1
Background: Poor glycaemic control with erratic blood glucose levels manifesting as recurrent hyperglycaemia with unpredictable episodes of hypoglycaemia is problem still faced today in daily practice. The causes include poor compliance and failure of oral hypoglycaemic. Despite being on insulin (38% of type 2 diabetes patients who require insulin treatment after 10 years) and type 1 diabetes patients continue to have fluctuating glucose concentration. The poor glycaemic control in insulin treated patients is due to insulin-induced lipohypertrophy. Lipohypertrophy has been known to be due to complication of insulin therapy for decades, but its prevalence is still high despite advance in technology. Around 2030% of type 1 diabetes patients, and around 4% of type 2 diabetes patients, develop lipohypertrophy.
Methods: We present a case report of a 64 years old man, type 2 diabetes for 20 years, and was on insulin therapy for 7 years. He was followed up by his General practitioner but referred to diabetic team due to erratic blood glucose level, ranging from 1.6 to 23 mmol/l.
Results: On assessment he had peripheral neuropathy with background diabetic retinopathy, and injection sites revealed significant lipohypertrophy on both thighs. His HbA1c was 10.9% with normal lipid profile, urea and electrolytes. He was advised to rotate injection sites and also reduce the dose of insulin by 24 units. His glycaemic control improved over the following 3 months with glucose levels of 4.611 mmol/l and his HbA1c fell to 7.8% despite reducing the dose of insulin.
Conclusion: Despite advance in technology insulin-induced lipohypertrophy remains common but neglected cause of poor glycaemic control today, in the past, and we should not allow this to be the case in future. All patients should be closely examined for lipohypertrophy during diabetic clinic review, using inspection, and palpation of injection sites in order not to miss subtle form of lipohypertrophy. Education to both doctors and patient about recognising and dealing with lipohypertrophy is advisable. The pathophysiology of lipohypertrophy is discussed in this case report.