Unexplained variability in glucose, unexpected hypoglycaemia, and a total daily dose that keeps creeping up are all commonly caused by the same thing: lipohypertrophy at a small number of favoured injection sites. Absorption from a lipohypertrophic area is slower and erratic, so the same dose behaves differently from day to day.
It is easy to miss because patients inject where it hurts least, which is exactly where the nerve endings have already been damaged. Examine the abdomen and thighs with the patient standing, look tangentially across the skin, and palpate — the rubbery thickening is often felt before it is seen. Ask the patient to show you where they inject rather than describing it.
The correction is rotation and needle length, not a bigger dose. Moving injections to normal tissue can drop insulin requirement substantially, so reduce the dose when you move the site and warn about hypoglycaemia. Reusing needles is the strongest modifiable driver, and in practice the cost of needles is the reason it happens — worth raising directly rather than assuming non-adherence.
- Inspect and palpate injection sites at every review, with the patient standing
- Ask the patient to demonstrate where and how they inject
- Moving to healthy tissue can reduce insulin requirement sharply — cut the dose and warn about hypoglycaemia
- Set a rotation scheme the patient can actually follow, and check it at the next visit
- Ask directly about needle reuse and its cost before assuming carelessness
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