When a stable insulin dose stops working, the site is a commoner explanation than the regimen. Lipohypertrophy is easy to miss on inspection alone: the change is in tissue consistency before it is visible, and patients favour hypertrophic areas precisely because injecting there hurts less.
The examination takes under a minute. Palpate flat-handed across each quadrant of the abdomen and both thighs, then pinch the tissue between finger and thumb - hypertrophy feels rubbery and slightly resistant against the softer fat around it. Mark what you find and put the patient's own hand on it; a site they can feel is a site they will avoid.
Absorption from hypertrophic tissue is erratic rather than uniformly reduced, which is why this presents as unexplained variability at least as often as a rising HbA1c. Titrating into that site widens the swings. Rotate first, re-check in two to four weeks, and titrate against the numbers that come back - and warn about hypoglycaemia, because moving injections to healthy tissue often means the total daily dose comes down.
- Palpate and pinch all abdominal quadrants and both thighs at any review where control has drifted
- Ask which site the patient actually uses - most name several and use one
- Check needle reuse; it travels with lipohypertrophy and is the cheaper thing to fix
- Warn about hypoglycaemia when injections move to healthy tissue, and expect to reduce the dose
- Re-examine in two to four weeks before deciding the regimen itself needs changing
Why it matters
Loss of control is attributed to adherence far more often than to the tissue the insulin is going into.
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