SAT108 What A Simple Switch Can Achieve; A Case Of Severe Insulin-induced Lipohypertrophy

Abstract

Abstract Disclosure: T. Ayub: None. L.A. Robles: None. S. Guntupalli: None. C.E. Guillen Lopez, MD: None. Introduction: Lipohypertrophy, a benign “tumor-like” swelling of the fatty tissue, is a common dermatological complication of subcutaneous insulin therapy. Here, we describe a case of severe skin lipohypertropy causing poorly controlled glycemic control requiring high insulin doses. However, after rotating the injection sites, followed a significant decrease in total daily dose (TDD) of insulin. Clinical Case: A 69-year-old female with a past medical history of type 2 diabetes mellitus (DM) for the last 16 years presented with uncontrolled blood glucose and gradually increasing insulin requirements. Hemoglobin A1c was 9.3%. Body mass index (BMI) of 32.59kg/m2. Home regimen insulin included long-acting insulin (Levemir), 50 units in the morning and 150 units at night, plus short-acting insulin (Humalog), 62 units with meals. Exenatide, Insulin Glargine, and Metformin were not tolerated in the past due to GERD-like side effects. An insulin pump was offered, but she preferred insulin injections. Patient endorsed good injection technique and adequate rotation between the inner and outer thighs. Surprisingly, physical examination revealed skin discoloration with hypertrophy on both thighs’ bilateral medial and later surfaces. Based on the history and skin examination, a clinical diagnosis of insulin-induced Lipohypertrophy was made. Patient was instructed to switch injection sites to the buttocks and provided with a new insulin regimen. Three months after initial visit, hemoglobin A1c dropped to 7.2%, and TDD of insulin was reduced by 48%, to Levemir 46 units twice daily, Humalog 30 units with breakfast/lunch, and 34 units with dinner. After seven months, her hemoglobin A1c dropped to 7% without further changes to the insulin regimen. Despite these changes, the lipohypertrophy had minimal changes. Discussion: The pathophysiology of lipohypertrophy is linked to a direct anabolic effect of insulin on local skin, inducing fat and protein synthesis. Risk factors include failure to rotate injection sites, needle reuse, female gender, high BMI, and long disease duration. Insulin injection in the lipohypertrophy areas can delay insulin absorption, causing glucose variability with unpredictable hyper and hypoglycemia episodes. There is no established therapeutic method to treat severe lipohyperthohy; avoiding further injection into that area is crucial, then surgical intervention can be considered. Currently, the best preventative and therapeutic strategies for insulin-induced lipohypertrophy include rotating injection sites and a single use of needles. Conclusion: This case emphasizes the importance of detailed inspection and palpation of insulin injecting sites regularly and how early intervention can lead to significant improvement in glycemic control, as described in our case. Presentation: Saturday, June 17, 2023