Lower risk of glycaemic variation

Impact of glycaemic variation

Investigators Blanco et al. ¹, diabetes Specialist Nurses in Spain, noticed that a number of patients frequently presented to clinic with recurring unexplained hypoglycaemia and glycaemic variation. 'They observed' a correlation between the presence of glycaemic variation and hypoglycaemia and the presence of lipohypertrophy.

They found in their study that¹:

Clinical Case Study cited in Blanco 2013¹

Clinical base-line characteristics and medical history:

• 32 year old male
• 18 year history of T1Diabetes
• Basal bolus insulin therapy - Glargine and Lispro Total Daily Dose (TDD) 136 units
• Levetiracetam (treatment for epilepsy)
• 12.7mm needle with reuse >10x
• HbA1c 6.9%
• Referred to neurology department May 2011with history of
  • Severe nocturnal hypoglycaemia
  • Tonic-clonic seizures since August 2010
  • Multiple emergency service call outs to his home because of seizures – severe hypo noted at time of seizure requiring Glucagon IM injections
  • Brain magnetic resonance imaging (MRI) and electroencephalogram (EEG) all negative
• Referred to Diabetes Unit in one of the study sites August 2012 – review showed:
  • Palpable lipohypertrophy lesions detected both sides of abdomen
  • Self-reported always injects into same lipohyperthrophy lesions

Clinical Lipohypertrophy

‘Echo-signature’ of Lipohypertrophy

Outcome after optimal injection technique intervention:

• Switched to 5mm pen needles (shortest available needle at the time) to minimise intramuscular risk
• ‘Single needle use only’ instruction reinforced
  • Educated to use correct injection technique including correct rotation and to avoid injecting into lipohypertrophy lesions
• Insulin dose reduced as a precaution against potential hypoglycaemia

Longer term follow up review and outcome:

• Follow up December 2012
• Self-reported
  • No seizures since August 2012
  • No emergency service call out since August 2012
  • No nocturnal hypoglycaemia since August 2012
  • Levetiracetam discontinued
• Subsequent reports of 2-3 day time hypoglycaemia per week
  • Insulin dose further reduced
• Total Daily Dose 48 units at most recent clinical review prior to publication of paper
  • Total Daily Dose of insulin reduced by 88 units compared to 136 units 5 months earlier
• HbA1C remained 6.9%

References

• ¹ Blanco M, et al. Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab (2013)