Endocrine Abstracts

Objective: Despite an increase ininsulin utilization in India over the past 10 years, wide variation exists in injection practices and usage across the Indian geography. This cross-sectional study was designed to audit various aspects of insulin usage, tolerability and efficacy of insulin regimens, degree of variability in injection techniques and its causes, interactions, and associations with glucose control and other outcomes.

Methods: Data for this cross-sectional retrospectivestudy was collected from the prescription registry of an electronic database including consecutive patients attendinga private urban referral clinic from North Eastern India between January 2006 until December 2016. T2DM patients using insulin for more than 3 months and having aninitial HbA1c level at registration were included. Information on patient demography, HbA_1c, insulin injection practices (including injection site, rotation, needle reuse, and lipohypertrophy), self-monitored blood glucose, and hypoglycemic events in the past 6 months were collected.

Results: Data of 1454 patients with T2DM (60.38% male, mean age 54.63 ± 10.79 years, range 18–85 years) on median duration of insulin therapy for 2.00 (0.0: 37) years were collected. Mean dose of insulin was 33.1 ± 17.8 units/day. Majority were taking human insulin (61.21%) andt he rest (34.59%) were on insulin analogues. Premix insulin (67.88%) was the most common type of insulin used followed by basal insulin (10.90%), basal bolus (6.50%), bolus only insulin (6.33%) and combination of premix with bolus (5.7%). 62.53% used pen device. OAD failure (33.15%), glucotoxicity (30.26%), and diabetic complications (20.36%) were prominentindications for starting insulin. Mean HbA1c(%) was 9.2 ± 2.2. Less than 16% of patients had HbA1c < 7%. Faulty injection practices were underscored by improper rotation of injection sites (67.61%) and needle reuse (73.11%). Majority followed right practices w.r t. storage (65.13%), hygiene (82.1%), correct site and angle for injection (78.4% and 81.84% respectively). Visible or palpable Liohypertrohy (LH) was found in 12.38% of subjects which was significantly associated with wrong rotation and needle reuse. Hypoglycemic events were insignificantly associated with type of insulin, or various attributes of insulin injection practices.

Discussion: This study, in spite of inherent limitations, convincingly shows that metabolic control remains poor amongst patients using insulin. Wrong injection practices, resultant LH and inadequate dose may be contributory.

Conclusion: There are identifiable faulty injection practices amongst T2DM patients on insulin, and therapeutic inertia amongst prescribing physicians which can be rectified by proper interventions targeting patients and HCPs.