Lipodystrophy in children with type 1 diabetes mellitus and variability of glycemia

Abstract

Objective — to optimize the prevention of complications of type 1 diabetes mellitus (DM 1) by diagnosing and preventing insulin­induced lipodystrophy (LD) and studying the effects of injection technique on glycemic variability. Materials and methods. The study included 235 patients with DM 1 aged 6—17 years (mean age 13.6 years) who were treated in the Department of Endocrinology of the Institute of Health Protection of Children and Adolescents NAMS of Ukraine. From them there were 125 (53.2 %) boys and 110 (46.8 %) girls. The mean DM 1 duration was 5.5 years (1 to 12 years). Patients were divided into two groups: the first consisted of 183 patients with LD (77.9 %), the second group included 52 children without LD (22.2 %). The groups were comparable in the compensation degree, DM duration and gender ratio. The LD was detected visually, by palpation, as well as according to the ultrasound examination (US) of the subcutaneous adipose tissue (SAT) of 385 insulin injection sites using the developed LD screening map. Blood circulation was investigated in the injured sites of SAT. In patients with LD and without it, the glycemic control parameters were calculated taking into account the coefficient of variability (CV) and time when glucose levels corresponded to the target range (time­in­range (TIR)). In case of detection of the pathologically altered SAT, a patient was introduced to the injection technique using short needles (4-5 mm) and indicated the places allowed for insulin injection. The clinical examinations and SAT ultrasound examinations were repeated in 6 months. Results and discussion. After 6 months, the high glycemia variability was revealed in 70 % of patients with LD (CV = 59.5 vs 38.2 %) and lower TIR parameters (TIR = 35.9 vs 55.7 %). TIR values correlated with HbA1c, and variability (CV) levels with the incidence of hypoglycemia and TBR, which was higher in patients with LD. That is 59.3 % of patients with HbA1c to 8.5 % had this figure greater than 50 % (r = 0.017, p < 0.05). The analysis of ultrasonic data from 385 injection sites revealed LD in 78 % of pediatric patients. The presence of various LD forms, caused by violations of injection technique, has been confirmed. Conclusions. With the help of ultrasound examinations of insulin injection sites, early diagnosis of the area of the lesion and the form of LD is possible, which additionally motivated 88 % of patients to follow the rules of insulin administration. It has been proven that timely diagnosis, training and implementation of the correct injection technique resulted in the leveling of the diffuse and mixed LD forms in the majority of patients (62 %). The most important risk factors for the development of insulin induced LD is a violation of injection techniques, namely: insufficient rotation of injection sites, injection of insulin into LD sites, small area of injection site, untimely change and excessive length of needles, namely the use of needles longer than 4—5 mm the number of injections with one needle and the content of the needle in the skin after the injection for more than 10 seconds. Lack of regular training at the School of Diabetes is a determining factor in the formation of low motivation to follow the rules of insulin administration. Thus, training in injection techniques is the basis of lipodystrophy prevention.Keywords: diabetes mellitus, insulin, injections, subcutaneous tissue, lipodystrophy, ultrasound investigation.