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Said R, Goda R, Abdalrahman IB, Erwa NHH. Case report: Insulin desensitization as the only option for managing insulin allergy in a Sudanese patient. FRONTIERS IN ALLERGY 2023; 4:1089966. [PMID: 37228579 PMCID: PMC10203528 DOI: 10.3389/falgy.2023.1089966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/10/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction Allergic reactions to insulin have become very rare with the introduction of human insulin. Anaphylaxis is a life-threatening condition that results from immediate IgE-mediated hypersensitivity. Desensitization to human insulin was reported to control immediate hypersensitivity reactions to insulin. Here, we describe the history and challenges of managing our patient and the development of an insulin desensitization protocol in a resource-limited setup. Case Summary A 42-year-old Sudanese woman with poorly controlled type 2 diabetes on maximum antidiabetic medications required insulin therapy to achieve reasonable glycemic control. She developed progressive and severe immediate hypersensitivity reactions to insulin, including anaphylaxis. Serum sample analysis demonstrated insulin-specific IgE antibodies. The patient's poor glycemic control and the need for breast surgery indicated insulin desensitization. A 4-day desensitization protocol was delivered in an ICU bed for close observation. Following successful desensitization and 24-h observation, our patient was discharged on pre-meal human insulin, which was tolerated well to the current date. Conclusions Although insulin allergy is rare, once encountered, it is very challenging in patients who have no other treatment options available. Different protocols for insulin desensitization are described in the literature; the agreed protocol was implemented successfully in our patient despite the limited resources.
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Affiliation(s)
- Rihan Said
- Endocrinology Unit, Department of Medicine, Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | - Rayan Goda
- Clinical Immunology and Allergy Unit, Soba University Hospital, Khartoum, Sudan
| | - Ihab B. Abdalrahman
- Department of Medicine, Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | - Nahla H. H. Erwa
- Clinical Immunology and Allergy Unit, Soba University Hospital, Khartoum, Sudan
- Department of Microbiology, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
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2
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Huang J, Yeung AM, Kerr D, Gentile S, Heinemann L, Al-Sofiani ME, Joseph JI, Seley JJ, Klonoff DC. Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks. Endocr Pract 2023:S1530-891X(23)00386-5. [PMID: 37098370 DOI: 10.1016/j.eprac.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To review the current status of practical knowledge related to insulin-associated lipohypertrophy (LH) - an accumulation of fatty subcutaneous nodules commonly caused by repeated injections and/or infusions of insulin into the same site. METHODS Review of published literature with additional contributions from leading multidisciplinary experts with the emphasis on clinical aspects including pathophysiology, clinical and economic consequences, diagnosis, prevention and treatment. RESULTS LH is the most common dermatologic complication of insulin therapy. Risk factors for the development of lipohypertrophy include repeated delivery of large amounts of insulin into the same location over time, repeated injection trauma to the skin and subcutaneous tissue, and multiple injections using the same needle. Subcutaneous insulin injection in skin areas with lipohypertrophy is associated with reduced pain; however, this problem can interfere with insulin absorption, thereby increasing the likelihood of glucose variability, hypo- and hyperglycemia when a site is changed. Modern visualization technology of the subcutaneous space with ultrasound can demonstrate lipohypertrophy early in the course of its development. CONCLUSIONS The physiological and psychological consequences of developing insulin lipohypertrophy can be prevented and treated with education focusing on insulin injection techniques.
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Affiliation(s)
- Jingtong Huang
- Diabetes Technology Society, Burlingame, California, USA.
| | - Andrea M Yeung
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, California, USA
| | - Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy; NefroCenter Research Network, Torre del Greco, Naples, Italy
| | | | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jeffrey I Joseph
- Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, California, USA; Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
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3
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Sola-Gazagnes A, Pecquet C, Berré S, Achenbach P, Pierson LA, Virmoux-Buisson I, M'Bemba J, Elgrably F, Moguelet P, Boitard C, Caillat-Zucman S, Laanani M, Coste J, Larger E, Mallone R. Insulin allergy: a diagnostic and therapeutic strategy based on a retrospective cohort and a case-control study. Diabetologia 2022; 65:1278-1290. [PMID: 35505238 DOI: 10.1007/s00125-022-05710-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/30/2022] [Indexed: 11/24/2022]
Abstract
AIMS/HYPOTHESIS Insulin allergy is a rare but significant clinical challenge. We aimed to develop a management workflow by (1) validating clinical criteria to guide diagnosis, based on a retrospective cohort, and (2) assessing the diagnostic performance of confirmatory tests, based on a case-control study. METHODS In the retrospective cohort, patients with suspected insulin allergy were classified into three likelihood categories according to the presence of all (likely insulin allergy; 26/52, 50%), some (possible insulin allergy; 9/52, 17%) or none (unlikely insulin allergy; 17/52, 33%) of four clinical criteria: (1) recurrent local or systemic immediate or delayed hypersensitivity reactions; (2) reactions elicited by each injection; (3) reactions centred on the injection sites; and (4) reactions observed by the investigator (i.e. in response to an insulin challenge test). All underwent intradermal reaction (IDR) tests. A subsequent case-control study assessed the diagnostic performance of IDR, skin prick and serum anti-insulin IgE tests in ten clinically diagnosed insulin allergy patients, 24 insulin-treated non-allergic patients and 21 insulin-naive patients. RESULTS In the retrospective cohort, an IDR test validated the clinical diagnosis in 24/26 (92%), 3/9 (33%) and 0/14 (0%) likely, possible and unlikely insulin allergy patients, respectively. In the case-control study, an IDR test was 80% sensitive and 100% specific and identified the index insulin(s). The skin prick and IgE tests had a marginal diagnostic value. Patients with IDR-confirmed insulin allergy were treated using a stepwise strategy. CONCLUSIONS/INTERPRETATION Subject to validation, clinical likelihood criteria can effectively guide diabetologists towards an insulin allergy diagnosis before undertaking allergology tests. An IDR test shows the best diagnostic performance. A progressive management strategy can subsequently be implemented. Continuous subcutaneous insulin infusion is ultimately required in most patients. CLINICALTRIALS gov: NCT01407640.
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Affiliation(s)
- Agnès Sola-Gazagnes
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France.
| | - Catherine Pecquet
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service d'Allergologie Dermatologie, Paris, France
| | - Stefano Berré
- Université Paris Cité, CNRS, Inserm, Institut Cochin, Paris, France
| | - Peter Achenbach
- Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Diabetes Research, Munich-Neuherberg, Germany
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Forschergruppe Diabetes, Munich, Germany
| | - Laure-Anne Pierson
- Assistance Publique-Hôpitaux de Paris, Hôtel-Dieu, Service de Pharmacie, Pharmacologie, Toxicologie, Paris, France
| | - Isabelle Virmoux-Buisson
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
| | - Jocelyne M'Bemba
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
| | - Fabienne Elgrably
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
| | - Philippe Moguelet
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service d'Anatomo-Pathologie, Sorbonne Université, Faculté de Médecine, Paris, France
| | - Christian Boitard
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
- Université Paris Cité, CNRS, Inserm, Institut Cochin, Paris, France
| | - Sophie Caillat-Zucman
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Laboratoire d'Immunologie, Paris, France
- Université Paris Cité, Inserm UMR976, Institut de Recherche Saint-Louis, Paris, France
| | - Moussa Laanani
- Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Cochin Hospital, Biostatistics and Epidemiology Unit, Paris, France
| | - Joel Coste
- Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Cochin Hospital, Biostatistics and Epidemiology Unit, Paris, France
| | - Etienne Larger
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
- Université Paris Cité, CNRS, Inserm, Institut Cochin, Paris, France
| | - Roberto Mallone
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
- Université Paris Cité, CNRS, Inserm, Institut Cochin, Paris, France
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Mohapatra L, Mangaraj S. Erythema annulare centrifugum associated with insulin therapy: a case report. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Liza Mohapatra
- SOA IMS and SUM Hospital, Kalinga Nagar Bhubaneswar 751003 India
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Sabah Abdulridha Budair A, Ismail Al Hamdi K, Ali Mansour A. Non-Infectious Dermatological Manifestations among Patients with Diabetes Mellitus in Basrah, Iraq. ARCHIVES OF RAZI INSTITUTE 2022; 77:467-475. [PMID: 35891736 DOI: 10.22092/ari.2021.356588.1874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/04/2021] [Indexed: 09/30/2022]
Abstract
Diabetes mellitus (DM) is a clinical illness usually linked to a wide range of skin manifestations; however, skin, as the greatest organ in the body, has received little attention. As a result, this study aimed to detect the prevalence and pattern of non-infectious skin disorders among patients with diabetes. This study was carried out at the Faiha Specialized Diabetes, Endocrine, and Metabolism Center, Basrah Province, Iraq, from September 2020 to September 2021. The data were collected from 347 patients with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM). The exclusion criteria were patients with skin changes due to some medications, pregnancy, iatrogenic factors, skin infections, established hypo- or hyper-thyroidism, Cushing or adrenal insufficiency, pituitary disorders, end-stage renal impairment, malignancy, and established rheumatological disease and those who were on chemotherapy. Full dermatological examinations and screenings were performed under the supervision of a dermatologist expert and all clinically definable cutaneous lesions were recorded. The prevalence of skin lesions was estimated at 71.5% in patients. Pruritus, xerosis, acrochordon, diabetic dermopathy, acanthosis nigricans, and insulin-related lipohypertrophy were the commonest skin lesions reported among the patients. The occurrence of skin lesions in diabetic patients was proportional to the female gender, duration of disease, obesity, insulin therapy, and worse glycemic control. There was a broad spectrum of skin lesions in both T1DM and T2DM with corresponding prevalence.
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Affiliation(s)
| | | | - A Ali Mansour
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center, University of Basrah, Basrah, Iraq
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6
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Sen S, Ali R, Onkar A, Ganesh S, Verma S. Strategies for interference of insulin fibrillogenesis: challenges and advances. Chembiochem 2022; 23:e202100678. [PMID: 35025120 DOI: 10.1002/cbic.202100678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/11/2022] [Indexed: 11/10/2022]
Abstract
The discovery of insulin came up with very high hopes for diabetic patients. In the year 2021, the world celebrated the 100 th anniversary of the discovery of this vital hormone. However, external use of insulin is highly affected by its aggregating tendency that occurs during its manufacturing, transportation, and improper handling which ultimately leads its pharmaceutically and biologically ineffective form. In this review, we aim to discuss the various approaches used for decelerating insulin aggregation which results in the enhancement of its overall structural stability and usage. The approaches that are discussed are broadly classified as either a measure through excipient additions or by intrinsic modifications in the insulin native structure.
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Affiliation(s)
- Shantanu Sen
- Indian Institute of Technology Kanpur, Chemistry, INDIA
| | - Rafat Ali
- Indian Institute of Technology Kanpur, Chemistry, Room No 131 Lab No2, CESE department IIT Kanpur, 208016, Kanpur, INDIA
| | - Akanksha Onkar
- Indian Institute of Technology Kanpur, Biological Sciences and Bioengineering, INDIA
| | - Subramaniam Ganesh
- Indian Institute of Technology Kanpur, Biological Sciences and Bioengineering, INDIA
| | - Sandeep Verma
- Indian Institute of Technology-Kanpur, Department of Chemistry, IIT-Kanpur, 208016, Kanpur, INDIA
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7
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Teo CB, Tan PY, Lee SX, Khoo J, Tan JG, Ang SF, Tan SH, Tay TL, Tan E, Lim SC, Boehm BO, Loh WJ. Insulin Allergy to Detemir Followed by Rapid Onset of Diabetic Ketoacidosis: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2022; 13:844040. [PMID: 35350098 PMCID: PMC8958006 DOI: 10.3389/fendo.2022.844040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
The management of diabetes mellitus in an insulin-dependent patient is challenging in the setting of concomitant antibody-mediated-insulin hypersensitivity. We report a case of a 62-year-old woman with pre-existing type 2 diabetes mellitus of 10 years duration who developed type 3 hypersensitivity reaction to insulin analogue detemir, and subsequently, severe diabetic ketoacidosis (DKA). She was C-peptide negative and was diagnosed with insulin-dependent diabetes. Despite increasing dose adjustments, insulin-meal matching, and compliance with insulin, she experienced episodes of unexpected hyperglycaemia and hypoglycaemia. The development of rash after detemir initiation and rapid progression to DKA suggests an aberrant immune response leading to the insulin allergy and antibody-induced interference with insulin analogues. Glycaemic control in the patient initially improved after being started on subcutaneous insulin infusion pump with reduced insulin requirements. However, after a year on pump therapy, localised insulin hypersensitivity reactions started, and glycaemic control gradually deteriorated.
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Affiliation(s)
- Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pek Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shan Xian Lee
- Department of Dermatology, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Jun Guan Tan
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sze Hwa Tan
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
| | - Bernhard O. Boehm
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
- Type 1 Diabetes Genetics Consortium (T1DGC) European Repository, Ulm University, Ulm, Germany
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- *Correspondence: Wann Jia Loh,
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8
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Tian K, Lee HY, Lim HB, Chan YL, Chong AH, Rama Chandran S, Gardner DSL. Rapid Desensitization for Insulin Allergy in Type 1 Diabetes Using an Insulin Pump: A Case Report and Literature Review. AACE Clin Case Rep 2021; 7:346-349. [PMID: 34765729 PMCID: PMC8573278 DOI: 10.1016/j.aace.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/09/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Insulin allergy, although uncommon, poses a significant challenge in those with type 1 diabetes mellitus (T1D) as insulin replacement is a necessity. Our objective is to describe a patient in whom rapid desensitization to insulin aspart was achieved using an insulin pump. Methods A 40-year-old woman with newly diagnosed T1D developed pruritic wheals over the abdomen after being injected with insulin glargine U-300 (Toujeo) and insulin aspart. Type 1 insulin hypersensitivity was confirmed through intradermal testing and positive insulin-specific immunoglobulin E levels. Result The patient underwent rapid desensitization with an insulin pump. Half the anticipated daily basal requirement was initially subcutaneously administered before initiating low-dose insulin via the pump (0.000025 units/h) and increasing the dose every 30 minutes to reach her basal requirements within 5 hours. Subsequent larger bolus insulin doses did not produce any local or anaphylactic reactions. No pretreatment with corticosteroids or antihistamines was provided. Conclusion Previous protocols for insulin desensitization span over days and often involve routine premedication. The case we presented suggests that insulin desensitization can be achieved over several hours using an insulin pump. A subcutaneous basal insulin cover should be provided prior to desensitization to avoid hyperglycemia necessitating an insulin bolus. Routine premedication may not always be necessary depending on reaction severity.
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Affiliation(s)
- Kristy Tian
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore
| | - Huee Boon Lim
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Yoke Ling Chan
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Ai Heong Chong
- Department of Endocrinology, Singapore General Hospital, Singapore
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Immunogenicity of Botulinum Toxin Formulations: Potential Therapeutic Implications. Adv Ther 2021; 38:5046-5064. [PMID: 34515975 PMCID: PMC8478757 DOI: 10.1007/s12325-021-01882-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/02/2021] [Indexed: 12/21/2022]
Abstract
Botulinum neurotoxins (BoNTs) are proteins produced by bacteria of the Clostridium family. Upon oral ingestion, BoNT causes the neuroparalytic syndrome botulism. There are seven serotypes of BoNT (serotypes A-G); BoNT-A and BoNT-B are the botulinum toxin serotypes utilized for therapeutic applications. Treatment with BoNT injections is used to manage chronic medical conditions across multiple indications. As with other biologic drugs, immunogenicity after long-term treatment with BoNT formulations may occur, and repeated use can elicit antibody formation leading to clinical nonresponsiveness. Thus, approaching BoNT treatment of chronic conditions with therapeutic formulations that minimize stimulating the host immune response while balancing patient responsiveness to therapy is ideal. Immunogenicity is a clinical limitation in many settings that use biologic drugs for treatment, and clinically relevant immunogenicity reduction has been achieved through engineering smaller protein constructs and reducing unnecessary formulation components. A similar approach has influenced the evolution of BoNT formulations. Three BoNT-A products and one BoNT-B product have been approved by the Food and Drug Administration (FDA) for therapeutic use: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB; a fourth BoNT-A product, daxibotulinumtoxinA, is currently under regulatory review. Additionally, prabotulinumtoxinA is a BoNT-A product that has been approved for aesthetic indications but not therapeutic use. Here, we discuss the preclinical and clinical immunogenicity data that exist within the scientific literature and provide a perspective for considering immunogenicity as a key factor in choice of BoNT formulation.
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Aberumand B, Jeimy S. The complexities of insulin allergy: a case and approach. Allergy Asthma Clin Immunol 2021; 17:79. [PMID: 34325725 PMCID: PMC8320219 DOI: 10.1186/s13223-021-00554-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Insulin hypersensitivity is rare, but challenging for individuals with diabetes. The prevalence of insulin allergy has decreased since the introduction of human recombinant insulin preparations. Hypersensitivity reactions range from injection site erythema and swelling, to anaphylaxis. While some reactions are to excipients (zinc, protamine, metacresol), many are to recombinant insulin itself. We present a case of type 1 hypersensitivity to various preparations of insulin in a patient with insulin-dependent type 2 diabetes mellitus (T2DM). Case presentation A 61-year-old woman with a 30-year history of insulin-dependent T2DM was referred for evaluation of reactions to insulin. She had two episodes over 5-months; both required Emergency Department visits and epinephrine administration. The first episode entailed a burning sensation of the extremities and nausea, immediately after injecting NovoRapid® insulin. The second event entailed a similar reaction but this time there was also angioedema of the upper airway with difficulty breathing and hypotension, immediately after injecting Levemir® and NovoRapid®, and taking metformin. There were no cofactors such as exercise, infectious illness, or NSAIDs use. Skin testing was performed with metformin, Lantus®, Humalog®, NovoRapid®, glulisine, insulin regular, NPH, Levemir® and the excipient protamine, as per published testing concentrations. Metacresol was not tested as its use was restricted by the hospital pharmacy. Insulin preparations with and without metacresol were included in testing however. A clinic staff served as a negative control. The patent had negative testing with protamine, but sensitization to all insulin preparations. Metformin skin testing and challenge along with latex IgE were negative. Subsequently, she underwent intentional weight loss of 70 lb, and was started on oral hypoglycemics with good effect. Conclusions Our case highlights the importance of diagnosing insulin allergy through a detailed history and focused testing. Therapeutic strategies include avoidance and insulin alternatives, alternate insulin preparations, or desensitization. In severe recurrent hypersensitivity reactions, Omalizumab or pancreatic transplantation have been effective.
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Affiliation(s)
- Babak Aberumand
- Division of Allergy and Immunology, Department of Medicine, University of Toronto, 30 Bond St. M5B 1W8, Toronto, ON, Canada.
| | - Samira Jeimy
- Division of Allergy and Immunology, Department of Medicine, Western University, London, ON, Canada
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11
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Shuster S, Borici-Mazi R, Awad S, Houlden RL. RAPID DESENSITIZATION WITH INTRAVENOUS INSULIN IN A PATIENT WITH DIABETIC KETOACIDOSIS AND INSULIN ALLERGY. AACE Clin Case Rep 2020; 6:e147-e150. [PMID: 32671215 PMCID: PMC7357611 DOI: 10.4158/accr-2019-0562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/25/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We report a case of insulin desensitization in a patient with known allergy to multiple insulin preparations who presented with diabetic ketoacidosis (DKA). METHODS Clinical and laboratory data, and desensitization protocols are presented. RESULTS A 65-year-old woman with type 2 diabetes and a documented insulin allergy presented with severe DKA. She was managed initially with intravenous (IV) fluids, sodium bicarbonate, and hemodialysis. An intradermal skin test was positive for 0.01 units/mL of human regular insulin. A rapid desensitization protocol for IV human regular insulin was initiated after pretreatment with methylprednisolone, ranitidine, montelukast, and cetirizine. An initial dilution of 1 unit of insulin in 100,000 mL of 0.9% sodium chloride was started at 5 mL/hour IV. The dilution was increased at 60-minute intervals to 1 unit/10,000 mL, 1 unit/1,000 mL, 1 unit/100 mL, 1 unit/10 mL, then 1 unit/1 mL. The dose was then increased from 1 to 7 units/hour (0.1 units/kg body weight/hour). The anion gap closed after 24 hours, and overlapping desensitization was started for subcutaneous (SC) human regular insulin starting with 0.00001 units with a gradual increase to 7 units before meals and 6 units at bedtime over 5 days. There were no anaphylactic reactions to IV or SC insulin. She was discharged with human regular insulin SC 4 times daily, oral montelukast, cetirizine, diphenhydramine as needed, and an epinephrine pen. No allergic reactions were reported at follow-up visits. CONCLUSION Rapid insulin desensitization is possible to allow treatment of DKA with human regular insulin IV in patients with known insulin allergy.
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12
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Fast simultaneous quantification of gabapentin and cetirizine in cell lysates by means of HPLC-MS/MS. J Pharm Biomed Anal 2020; 184:113172. [DOI: 10.1016/j.jpba.2020.113172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/07/2020] [Accepted: 02/12/2020] [Indexed: 11/18/2022]
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13
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Colson F, Nikkels AF, Dezfoulian B. Allergy to metacresol in a type 2 diabetes patient. Contact Dermatitis 2020; 82:316-318. [DOI: 10.1111/cod.13467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Fany Colson
- Department of DermatologyLiège University Hospital, CHU of Sart‐Tilman Liège Belgium
| | - Arjen F. Nikkels
- Department of DermatologyLiège University Hospital, CHU of Sart‐Tilman Liège Belgium
| | - Bita Dezfoulian
- Department of DermatologyLiège University Hospital, CHU of Sart‐Tilman Liège Belgium
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14
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Pham NB, Liu W, Schueller NR, Gawalt ES, Fan Y, Meng WS. Toward reducing biomaterial antigenic potential: a miniaturized Fc-binding domain for local deposition of antibodies. Biomater Sci 2019; 7:760-772. [PMID: 30574644 PMCID: PMC6410374 DOI: 10.1039/c8bm01220b] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
A peptide derived from staphylococcal protein A (SpA) was developed as an affinity module for antibody delivery applications. The miniaturized protein consists of the first helix of the engineered SpA Z domain fused with the self-assembling peptide (SAP) AEAEAKAKAEAEAKAK, or EAK. The resulting peptide, named Z15_EAK, was shown to possess fibrillization properties and an Fc-binding function. The peptide induced a red shift in the Congo red absorbance characteristic of peptide fibrils, also evidenced in transmission electron microscopy images. The one-site binding affinity (Kd) of a gel-like coacervate generated by admixing Z15_EAK with EAK for IgG was determined to be 1.27 ± 0.14 μM based on a microplate-based titration assay. The coacervate was found to localize IgG subcutaneously in mouse footpads for 8 to 28 days. A set of in vivo data was fit to a one-compartment model for simulating the relative fractions of IgG dissociated from the materials in the depot. The model predicted that close to 27% of the antibodies injected were available unbound for the duration of the experiment. Z15_EAK did not appear to induce innate immune responses; injecting Z15_EAK into mouse footpads elicited neither interleukin-6 (IL-6) nor tumor necrosis factor-alpha (TNF-α) from splenocytes isolated from the animals one day, seven days, or eleven days afterward. The antigenic potential of Z15 was analyzed using a bioinformatic approach in predicting sequences in SpA and Z15 dually presented by class I and class II human MHC alleles covering the majority of the population. A peptide in SpA identified as a potential T cell epitope cross reacting with a known epitope in a microbial antigen was eliminated by miniaturization. These results demonstrate that Z15_EAK is a potential platform for generating antibody depots by which the impacts of Fc-based biotherapeutics can be enhanced through spatiotemporal control.
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Affiliation(s)
- Ngoc B Pham
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA 15282, USA.
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15
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Successful management of type IV hypersensitivity reactions to human insulin analogue with injecting mixtures of biphasic insulin aspart and dexamethasone. J Formos Med Assoc 2019; 118:843-848. [PMID: 30704815 DOI: 10.1016/j.jfma.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/16/2018] [Accepted: 01/07/2019] [Indexed: 11/22/2022] Open
Abstract
Although hypersensitivity reaction to insulin was supposed to be less-frequent with current insulin analogue, case reports with different types of allergic reactions to insulin analogue were still reported. The most common form is type I hypersensitivity reaction with IgE-mediated. Besides, type III (IgG and IgM-mediated) and type IV (T-cell mediated delayed reaction) hypersensitivity reactions were also reported. Here we presented a long-standing type 2 diabetes with insulin requirements with hypersensitivity reactions to insulin actrapid, insulin aspart, insulin glargine, insulin detemir, and biphasic insulin aspart 30. Insulin desensitization was performed as initial management but failed as skin biopsy with immunohistochemical staining proved type IV hypersensitivity reaction. We continued with the next treatment approach using subcutaneous injection with the mixture of biphasic insulin aspart 30 and dexamethasone to alleviate allergy, and the result was successful with steroid-free biphasic insulin aspart 30 injection eight months later. Besides, the treatment effect had lasted after ten years even with switched type of insulin analogue from biphasic insulin aspart 30 to insulin glargine and insulin aspart. The case report demonstrated a good example of how clinicians deal with the rare but important questions of hypersensitivity reactions to insulin analogue.
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16
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Haastrup MB, Henriksen JE, Mortz CG, Bindslev-Jensen C. Insulin allergy can be successfully managed by a systematic approach. Clin Transl Allergy 2018; 8:35. [PMID: 30258565 PMCID: PMC6154953 DOI: 10.1186/s13601-018-0223-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/22/2018] [Indexed: 12/25/2022] Open
Abstract
Background Type I insulin allergy can be a challenging condition, and there is no international consensus on how to establish the diagnosis. Measurement of specific IgE and skin testing have been cornerstones in the diagnostic work-up. However, these tests have limitations, mainly lack of correlation between test results and clinical findings. At the Allergy Centre, Odense University Hospital, patients with suspected insulin allergy have been evaluated since 2003. The aim of this study was to establish a systematic approach to diagnose and treat patients with insulin allergy.
Methods The study was conducted retrospectively by retrieving data from the Allergy Centre database on patients with suspected insulin allergy evaluated from 2003 to 2017. The examination comprised a comprehensive medical history, specific IgE against insulin and intracutaneous tests (ICT) with different insulins. Results A total of 144 patients were examined on suspicion of insulin allergy of which 110 had negative specific IgE in serum. Of the remaining 34 patients, 33 had ICT performed; 2 had negative ICTs, while 31 had one or more positive ICT. All 34 patients had mild symptoms, and 4 could obtain symptom relief with antihistamines or local steroids, 9 could be managed with oral antidiabetics, and 7 were switched to other insulins. The final 14 patients were offered an insulin pump because of reactions to many different insulins, many positive ICTs, unmanageable diabetes, young age and compliance, or convenience. Conclusion Insulin allergy can be managed by a systematic approach, and symptom relief is obtainable in most patients.
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Affiliation(s)
- Maija Bruun Haastrup
- 1Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Jan Erik Henriksen
- 2Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Charlotte Gotthard Mortz
- 3Odense Research Center for Anaphylaxis (ORCA), Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Carsten Bindslev-Jensen
- 3Odense Research Center for Anaphylaxis (ORCA), Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
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17
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Oray NC, Bayram B, Altintas E, Sivrikaya S, Savran Y. Severe allergic reaction to human insulin in the patient with diabetic ketoacidosis. Turk J Emerg Med 2018; 18:40-41. [PMID: 29942883 PMCID: PMC6009812 DOI: 10.1016/j.tjem.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/17/2017] [Accepted: 07/26/2017] [Indexed: 11/25/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is an acute and major life-threatening complication of diabetes mellitus. Fluid resuscitation, insulin therapy, and electrolyte replacement are essential for DKA treatment. Rarely, life threatening allergic reactions might develop in a patient treated with insulin. If anaphylaxis develops after insulin, the DKA treatment options are restricted. A limited number of case reports have been reported in patients with severe anaphylactic reactions to human insulin who were then treated with synthetic insulin analogues. We present a case of a 45-year-old male patient with allergic reactions to human insulin. The patient was successfully treated with insulin aspart and hemodialysis.
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Affiliation(s)
- Nese Colak Oray
- Dokuz Eylul University, Faculty of Medicine, Department of Emergency Medicine, Balcova, 35340, Izmir, Turkey
| | - Basak Bayram
- Dokuz Eylul University, Faculty of Medicine, Department of Emergency Medicine, Balcova, 35340, Izmir, Turkey
| | - Emel Altintas
- Adiyaman University, Training and Research Hospital, Department of Emergency Medicine, Adiyaman, Turkey
| | - Semra Sivrikaya
- Artvin State Hospital, Department of Emergency Medicine, Artvin, Turkey
| | - Yusuf Savran
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Balcova, 35340, Izmir, Turkey
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18
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Bertuzzi F, Meneghini E, Bruschi E, Luzi L, Nichelatti M, Epis O. Ultrasound characterization of insulin induced lipohypertrophy in type 1 diabetes mellitus. J Endocrinol Invest 2017; 40:1107-1113. [PMID: 28452000 DOI: 10.1007/s40618-017-0675-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 04/09/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Subcutaneous insulin absorption is one of the key factors affecting glycemic control in patients with diabetes mellitus under insulin therapy. Insulin-induced subcutaneous lipohypertrophy has been reported to impair insulin regular absorption and hence glycemic control. So far, lipohypertrophy diagnosis has only been clinical. This study aims at evaluating the possible role of ultrasound scan in the assessment of subcutaneous lipohypertrophy in patients affected by type 1 diabetes mellitus. METHODS A pilot observational retrospective study was performed in 20 patients affected by type 1 diabetes mellitus. In these patients the areas with clinical evidence of lipohypertrophy dependent on the insulin injections were characterized by the presence of tissues that at the ultrasound scan resulted similar to fibrotic tissues (hyperechogenic) or to an interstitial edema or to fat tissues (hypoechogenic). It was utilized a multi frequency linear probe (6-18 MHz). The patients were advised to avoid insulin injections on the areas with lipohypertrophy scanned by the ultrasound and the HbA1c changes were evaluated 3 months later. RESULTS The lipohypertrophic areas presented at least three different aspects upon ultrasound assessment: the iso-hyperechogenic one, with a predominant fibrotic component; the isoechogenic one, with "large tangles" fibrotic elements and the iso-hypoechogenic aspect with no fibrotic elements. When patients were advised to avoid insulin injections on areas with lipohypertrophy defined by ultrasound scan, 3 months after the first evaluation HbA1c had significantly improved (basal HbA1c 7.87 ± 0.56 versus 7.67 ± 0.52 3 months later, p = 0.029). No significant improvements of the HbA1c were found in the control matched group in which lipohypertrophy was only clinically valued through inspection and palpation. CONCLUSIONS Ultrasound scan can help identify and characterize the lipohypertrophic areas and this might be useful to improve glycemic control.
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Affiliation(s)
- F Bertuzzi
- Diabetes Unit, SSD Diabetologia, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - E Meneghini
- SS Diabetologia, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - E Bruschi
- SC Reumatologia, Niguarda Ca' Granda Hospital, Milan, Italy
| | - L Luzi
- Metabolism Research Center and Endocrinology and Metabolism, IRCCS Policlinico San Donato Milanese, Milan, Italy
- Department of Biomedical and Health Sciences, University of Milan, Milan, Italy
| | - M Nichelatti
- Service of Biostatistics Niguarda Cancer Center, Niguarda Ca' Granda Hospital, Milan, Italy
| | - O Epis
- SC Reumatologia, Niguarda Ca' Granda Hospital, Milan, Italy
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19
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Murray BR, Jewell JR, Jackson KJ, Agboola O, Alexander BR, Sharma P. Type III Hypersensitivity Reaction to Subcutaneous Insulin Preparations in a Type 1 Diabetic. J Gen Intern Med 2017; 32:841-845. [PMID: 28337685 PMCID: PMC5481240 DOI: 10.1007/s11606-017-4037-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/02/2017] [Accepted: 03/01/2017] [Indexed: 11/29/2022]
Abstract
Management of type 1 diabetes in patients who have insulin hypersensitivity is a clinical challenge and places patients at risk for recurrent diabetic ketoacidosis (DKA). Hypersensitivity reactions can be due to the patient's response to the insulin molecule itself or one of the injection's non-insulin components. It is therefore crucial for clinicians to quickly recognize the type of hypersensitivity reaction that is occurring and identify potentially immunogenic additives for the purpose of directing therapy as various insulin preparations have differing ingredients. We present the case of a 23-year-old diabetic female with common variable immunodeficiency (CVID) and autoimmune enteropathy who developed a type III hypersensitivity reaction to multiple formulations of subcutaneous insulin after years of use and the challenges of devising a long-term management strategy.
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Affiliation(s)
- Benjamin R Murray
- Duke University School of Medicine, 3643 N Roxboro Rd, Durham, NC, 27704, USA
| | - Jolene R Jewell
- Duke University School of Medicine, 3643 N Roxboro Rd, Durham, NC, 27704, USA
| | - Kyle J Jackson
- Duke University School of Medicine, 3643 N Roxboro Rd, Durham, NC, 27704, USA
| | - Olabunmi Agboola
- Duke University School of Medicine, 3643 N Roxboro Rd, Durham, NC, 27704, USA
| | | | - Poonam Sharma
- Duke University School of Medicine, 3643 N Roxboro Rd, Durham, NC, 27704, USA.
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20
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A case of local delayed-type allergy to zinc-containing insulin as a cause of diabetic ketoacidosis in a patient with type 1 diabetes mellitus undergoing continuous subcutaneous insulin infusion. Diabetol Int 2016; 7:447-450. [DOI: 10.1007/s13340-016-0264-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/02/2016] [Indexed: 11/26/2022]
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21
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Thalange N, Bereket A, Jensen LB, Hiort LC, Peterkova V. Development of Insulin Detemir/Insulin Aspart Cross-Reacting Antibodies Following Treatment with Insulin Detemir: 104-week Study in Children and Adolescents with Type 1 Diabetes Aged 2-16 Years. Diabetes Ther 2016; 7:713-724. [PMID: 27600385 PMCID: PMC5118234 DOI: 10.1007/s13300-016-0196-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To study the long-term development (104 weeks) of insulin antibodies during treatment with insulin detemir (IDet) and insulin aspart (IAsp) in children with type 1 diabetes aged 2-16 years. METHODS A 52-week, two-arm, randomized trial comparing IDet and neutral protamine Hagedorn insulin, both in combination with IAsp, was followed by a one-arm, 52-week extension trial of the IDet + IAsp arm. The present analysis was conducted in children who completed the randomized trial and entered into the extension trial. RESULTS Of the 177 children randomized to IDet treatment, 146 entered the extension trial. IDet-IAsp cross-reacting antibodies peaked within the first 39 weeks of treatment before gradually declining. A similar pattern was seen for IDet-specific and IAsp-specific antibodies. At end of trial (EOT), no correlation was observed between the level of IDet-specific or IAsp-specific antibodies or IDet-IAsp cross-reacting antibodies and either glycated hemoglobin (HbA1c) or basal insulin dose. Mean HbA1c was stable during the treatment period, with a slight increase over time from 8.41% (68.4 mmol/mol) at baseline to 8.74% (72 mmol/mol) at EOT. Mean IDet dose increased from 0.43 U/kg at baseline to 0.66 U/kg at EOT. Mean IAsp dose increased from 0.46 U/kg to 0.51 U/kg at EOT. CONCLUSION Although treatment with IDet and IAsp is associated with development of specific and cross-reacting antibodies, no correlation between insulin antibodies and basal insulin dose or HbA1c was found. FUNDING Novo Nordisk A/S. ClinicalTrials.gov identifiers: NCT00435019 and NCT00623194.
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Affiliation(s)
- Nandu Thalange
- Jenny Lind Children's Department, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Abdullah Bereket
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | | | | | - Valentina Peterkova
- Endocrinological Research Centre, Institute of Paediatric Endocrinology, Moscow, Russia
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22
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Murphy LA, Zuendt GF, Nakamura RK, Gambardella P. Hypersensitivity reaction associated with subcutaneous glargine insulin therapy in a cat. JFMS Open Rep 2016; 2:2055116916668892. [PMID: 28491437 PMCID: PMC5362920 DOI: 10.1177/2055116916668892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/15/2022] Open
Abstract
CASE SUMMARY A 14-year-old, domestic shorthair cat was treated for transient diabetes mellitus for 3 months with glargine insulin, which was discontinued when the diabetes mellitus resolved. Approximately 36 months later the diabetes mellitus recurred and glargine insulin was restarted. Within 2-3 mins of the first injection the cat collapsed, developed profuse vomiting and diarrhea, as well as facial swelling and diffuse erythema. A hypersensitivity reaction was suspected and the cat was treated with antihistamines, aggressive fluid therapy and gastrointestinal support. The cat made a full recovery and was discharged 3 days later. Six months later the cat re-presented for relapse of its diabetes mellitus and an intradermal skin challenge with 1:20 diluted insulin was performed confirming a hypersensitivity to glargine. The cat continues to be well regulated on porcine zinc insulin without any hypersensitivity reactions noted. RELEVANCE AND NOVEL INFORMATION Hypersensitivity reactions to insulin administration are rarely described in human medicine. This is the first reported case of a hypersensitivity reaction secondary to glargine insulin in a cat. Clinicians should be aware of this potential complication, particularly in animals with a previous history of insulin administration and the potential to utilize intradermal testing with insulin.
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Affiliation(s)
- Lisa A Murphy
- Oradell Animal Hospital, Emergency Department, Paramus, NJ, USA
| | - Greg F Zuendt
- Oradell Animal Hospital, Emergency Department, Paramus, NJ, USA
| | - Reid K Nakamura
- Veterinary Specialty and Emergency Center, Emergency and Cardiology Departments, Thousand Oaks, CA, USA
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23
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Yuan T, Zhao W, Wang L, Dong Y, Li N. Continuous Subcutaneous Insulin Infusion as an Effective Method of Desensitization Therapy for Diabetic Patients with Insulin Allergy: A 4-year Single-center Experience. Clin Ther 2016; 38:2489-2494.e1. [PMID: 27793354 DOI: 10.1016/j.clinthera.2016.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE This article summarizes our experiences in the application of continuous subcutaneous insulin infusion (CSII) as a method of rapid desensitization therapy for diabetic patients with insulin allergy that was subsequently switched to a regimen of multiple-dose injections for long-term insulin therapy. METHODS The clinical data of 11 diabetic patients with insulin allergy in Peking Union Medical College Hospital from April 1, 2008, through December 31, 2011, were retrospectively analyzed. FINDINGS All 11 conditions were diagnosed by case history, skin testing, determination of serum specific anti-insulin IgE, and reaction to withdrawal of insulin. Seven patients accepted the traditional injection method of desensitization, and 5 patients accepted CSII with the protocol designed for this study (1 patient accepted CSII after failure by the formal method). Six of the 7 patients who accepted the traditional method and all 5 patients who accepted CSII had successful results. All 5 patients in the CSII group switched to a regimen of multiple dosage injections. In a survey of 28 nurses, both experienced nurses and practical nurses preferred to use CSII as the method of desensitization. IMPLICATIONS It is feasible and effective for diabetic patients with insulin allergy to use CSII as a method of rapid desensitization with subsequent switching to a regimen of multiple-dose injections for long-term insulin therapy.
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Affiliation(s)
- Tao Yuan
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Health and Family Planning Commission, Beijing, China
| | - Weigang Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Health and Family Planning Commission, Beijing, China
| | - Lianglu Wang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yingyue Dong
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Health and Family Planning Commission, Beijing, China
| | - Naishi Li
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Health and Family Planning Commission, Beijing, China.
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24
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Badik J, Chen J, Letvak K, So TY. Hypersensitivity Reaction to Insulin Glargine and Insulin Detemir in a Pediatric Patient: A Case Report. J Pediatr Pharmacol Ther 2016; 21:85-91. [PMID: 26997933 DOI: 10.5863/1551-6776-21.1.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Allergy to human insulin or its analogs is rare, but it is still a significant issue in current diabetes care. Allergic reactions can range from localized injection site reactions to generalized anaphylaxis, and they can be caused by excipients or the insulin molecules themselves. We presented a case of a 14-year-old male patient with generalized allergic reactions to insulin glargine and insulin detemir. The patient was successfully managed by being switched to a continuous subcutaneous insulin infusion with insulin aspart. Allergic reactions to insulin detemir and insulin glargine have both been well described, with insulin detemir allergy appearing to be more common. There are several potential mechanisms for insulin allergy, and immunologic characteristics vary among different insulin analogs. After confirming insulin allergy in practice, management involves treating symptoms and switching insulin preparations. This is the first documented case of allergies to both insulin glargine and insulin detemir in a pediatric patient. Exact mechanism of insulin allergy is unknown, and management strategies must be individualized for each patient.
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Affiliation(s)
- Jennifer Badik
- Department of Pediatric Endocrinology, Cone Health Pediatric Sub-Specialists of Greensboro, Greensboro, North Carolina
| | - Jimmy Chen
- Medical Student, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kira Letvak
- University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Tsz-Yin So
- Department of Pharmacy, Moses H. Cone Hospital, Greensboro, North Carolina
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25
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Choi SJ, Kwon MK, Park M, Bae SY, Oh HH, Lee JH, Moon JI, Park CS, Won JC, Ko KS, Rhee BD, Kim JM. Allergic reaction to recombinant human insulin. ALLERGY ASTHMA & RESPIRATORY DISEASE 2015. [DOI: 10.4168/aard.2015.3.4.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Seong Jin Choi
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Min Kwan Kwon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Moon Park
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Soo Ya Bae
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hyun Ho Oh
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jong Ho Lee
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Ji In Moon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Chan Sun Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jong Chul Won
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kyung Soo Ko
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Byoung Doo Rhee
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jung Min Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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26
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Fidalgo O, Jorge S, Veleiro B, Isidro ML. A Case of Skin, and Secondarily Generalized, Reaction to Insulin Injection. Clin Diabetes 2014; 32:127-9. [PMID: 26246684 PMCID: PMC4521437 DOI: 10.2337/diaclin.32.3.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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27
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Pitrola D, MacIver C, Mallipedhi A, Udiawar M, Price DE, Stephens JW. Cutaneous allergy to insulin: could statins and ACE inhibitors play a role? A case report. Diabetes Res Clin Pract 2014; 104:e20-2. [PMID: 24534533 DOI: 10.1016/j.diabres.2014.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 12/23/2013] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
Insulin allergy is rare. Both statins and angiotensin converting enzyme (ACE) inhibitors may cause local urticarial skin reactions and have been implicated to precipitate local reactions to insulin. We describe a case of a localised urticarial allergic reaction related to insulin use in a patient co-prescribed an ACE inhibitor and statin.
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Affiliation(s)
- D Pitrola
- Department of Diabetes & Endocrinology, Morriston Hospital, ABM University NHS Trust, Swansea SA6 6NL, United Kingdom
| | - C MacIver
- Department of Diabetes & Endocrinology, Morriston Hospital, ABM University NHS Trust, Swansea SA6 6NL, United Kingdom
| | - A Mallipedhi
- Department of Diabetes & Endocrinology, Morriston Hospital, ABM University NHS Trust, Swansea SA6 6NL, United Kingdom; Diabetes Research Group, Swansea University, Singleton Park, Swansea SA2 8PP, United Kingdom
| | - M Udiawar
- Department of Diabetes & Endocrinology, Morriston Hospital, ABM University NHS Trust, Swansea SA6 6NL, United Kingdom
| | - D E Price
- Department of Diabetes & Endocrinology, Morriston Hospital, ABM University NHS Trust, Swansea SA6 6NL, United Kingdom
| | - J W Stephens
- Department of Diabetes & Endocrinology, Morriston Hospital, ABM University NHS Trust, Swansea SA6 6NL, United Kingdom; Diabetes Research Group, Swansea University, Singleton Park, Swansea SA2 8PP, United Kingdom.
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28
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Reznik Y, Cohen O. Insulin pump for type 2 diabetes: use and misuse of continuous subcutaneous insulin infusion in type 2 diabetes. Diabetes Care 2013; 36 Suppl 2:S219-25. [PMID: 23882049 PMCID: PMC3920779 DOI: 10.2337/dcs13-2027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Yves Reznik
- Endocrinology and Diabetes Department, CHU Côte de Nacre, Caen Cedex, France.
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Abstract
INTRODUCTION In 2009, several epidemiological studies suggested a higher frequency of malignancy in insulin glargine -treated patients. A number of follow-up epidemiological population studies as well as two randomized, controlled clinical studies, one a 5000-patient retinopathy study and the other a 12,000-patient cardiovascular outcomes trial (ORIGIN), found no higher frequency of malignancy in glargine-treated patients. AREAS COVERED We reviewed the existing literature as well as U.S. FDA records to investigate the association of cancer, diabetes, and insulin. There is a 20 - 40% higher incidence of malignancy in type 2 diabetes patients. Certain cancers are more common, including hepatocellular and pancreatic carcinoma, colorectal cancer, renal cancer, and breast and endometrial cancer, and non-Hodgkin's lymphoma. There are numerous inter-related factors which may promote both diabetes and malignancy, including dietary patterns, obesity, insulin resistance, and alcoholism. Patients who receive insulin treatment are typically older and "sicker" than those who receive oral agents. EXPERT OPINION It is very difficult to prove causal associations between diabetes and cancer due to the host of confounding factors. The hypothesis that hyperinsulinemia and IGF-1 receptor activation promote cancer is strong, but confounded by the association of hyperinsulinemia with obesity, which separately promotes malignancy. Although statistical techniques to adjust for confounding variables can improve epidemiological comparisons, the lesson of the glargine cancer controversy is that controlled clinical trials are the only means to definitely prove hypotheses.
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Affiliation(s)
- Marc Rendell
- Creighton Diabetes Center, 601 North 30th Street, Omaha, NE 68131, USA.
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Wu P, Ji C, Wang M, Zou S, Ge W. Desensitization of allergy to human insulin and its analogs by administering insulin aspart and insulin glargine. ANNALES D'ENDOCRINOLOGIE 2013; 74:56-8. [PMID: 23351561 DOI: 10.1016/j.ando.2012.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 11/19/2012] [Indexed: 11/25/2022]
Abstract
Insulin allergy is a rare clinical situation. We report a 51-year-old patient with type 2 diabetes who required multiple daily insulin injections. The patient developed allergy to human regular insulin and insulin analogs (insulin aspart and insulin glargine), which was resolved by subcutaneous insulin desensitization.
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Affiliation(s)
- Ping Wu
- Department of pharmacology, 3rd affiliated hospital, Soochow university, Jiangsu Changzhou, China
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Wheeler BJ, Taylor BJ. Successful management of allergy to the insulin excipient metacresol in a child with type 1 diabetes: a case report. J Med Case Rep 2012; 6:263. [PMID: 22937994 PMCID: PMC3469394 DOI: 10.1186/1752-1947-6-263] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 07/05/2012] [Indexed: 12/13/2022] Open
Abstract
Introduction Insulin allergy to human insulin preparations during the treatment of diabetes is suggested to occur at rates ranging from <1.0% to 2.4%. These reactions vary from mild localized reactions, which resolve with repeated exposure, to life-threatening anaphylaxis and death. The management of persistent insulin allergy in type 1 diabetes mellitus is particularly complicated because ongoing treatment with insulin is essential. Case presentation We present the case of a 12-year-old Caucasian girl with localized allergy to the insulin excipient metacresol, and the subsequent desensitization therapy using continuous subcutaneous insulin infusion with simultaneous intravenous insulin infusion. Conclusions This is the first documented case of allergy to the metacresol component of insulin in the pediatric type 1 diabetes literature. We describe an approach to diagnosis and management of metacresol allergy in type 1 diabetes.
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Affiliation(s)
- Benjamin J Wheeler
- Department of Women's and Children's Health, University of Otago, Dunedin, 9054, New Zealand.
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A case of glycemic instability and insulin allergy due to anti-insulin antibodies in a patient with type 2 diabetes. Diabetol Int 2012. [DOI: 10.1007/s13340-012-0077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Crameri R. Immunoglobulin E-binding autoantigens: biochemical characterization and clinical relevance. Clin Exp Allergy 2011; 42:343-51. [PMID: 22092496 DOI: 10.1111/j.1365-2222.2011.03878.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 07/20/2011] [Accepted: 09/02/2011] [Indexed: 01/14/2023]
Abstract
Although immediate-Type I skin reactions to human dander have been described six decades ago, only the recent application of molecular biology to allergology research allowed fast and detailed characterization of IgE-binding autoantigens. These can be functionally subdivided into three classes: (1) self-antigens with sequence homology to environmental allergens belonging to the class of phylogenetically conserved proteins, (2) self-antigens without sequence homology to known environmental allergens, and (3) chemically modified self-antigens deriving from workplace exposure. As environmental allergens, also IgE-binding autoantigens belong to different protein families without common structural features that would explain their IgE-binding capability. Many of the self-antigens showing sequence homology to environmental allergens, are phylogenetically conserved proteins like manganese dependent superoxide dismutase, thioredoxin or cyclopilin. Their IgE-binding capability can be explained by molecular mimicry resulting from shared B-cell epitopes. A common factor of IgE-binding self-antigens without sequence homology to known environmental allergens is that they elicit IgE responses only in individuals suffering from long-lasting atopic diseases. In contrast, IgE-mediated reactions to modified self-antigens might be explained with the generation of novel B-cell epitopes. Chemically modified self-antigens are likely to be recognized as non-self by the immune system. The clinical relevance of IgE responses to self-antigens remains largely unclear. Well documented is their ability to induce immediate Type I skin reactions in vivo, and to induce mediator release from effector cells of sensitized individuals in vitro. Based on these observations it is reasonable to assume that IgE-mediated cross-linking of FcRIε receptors on effector cells can elicit the same symptoms as those induced by environmental allergens, and this could explain exacerbations of chronic allergic diseases in the absence of external exposure. However, because most of the described IgE-binding self-antigens are intracellular proteins normally not accessible for antigen-antibody interactions, local release of the antigens is required to explain the induction of symptoms.
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Affiliation(s)
- R Crameri
- Department Molecular Allergology, Swiss Institute of Allergy and Asthma Research, Obere Strasse 22, CH-7270 Davos, Switzerland.
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Abstract
BACKGROUND Insulin allergy is a rare complication of insulin use. Localized lipoatrophy is also known to occur following subcutaneous injections of insulin. CASE REPORT A 53-year-old non-obese female patient with Type 2 diabetes displayed local allergic-type symptoms to all available insulin preparations. This was complicated by the development of severe lipoatrophy on her abdominal and thigh injection sites and subsequently resulted in suboptimal glycaemic control. CONCLUSIONS Whilst uncommon, insulin allergy and lipoatrophy can cause major problems in diabetic management. Potential pathophysiological mechanisms and a stepwise approach to management are discussed.
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Affiliation(s)
- A N Tavare
- Department of Diabetes and Endocrinology, The Hillingdon Hospital, Uxbridge, UK.
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36
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Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 652] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
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Reznik Y. Continuous subcutaneous insulin infusion (CSII) using an external insulin pump for the treatment of type 2 diabetes. DIABETES & METABOLISM 2010; 36:415-21. [DOI: 10.1016/j.diabet.2010.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 08/13/2010] [Accepted: 08/13/2010] [Indexed: 10/19/2022]
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Cernadas JR, Brockow K, Romano A, Aberer W, Torres MJ, Bircher A, Campi P, Sanz ML, Castells M, Demoly P, Pichler WJ. General considerations on rapid desensitization for drug hypersensitivity - a consensus statement. Allergy 2010; 65:1357-66. [PMID: 20716314 DOI: 10.1111/j.1398-9995.2010.02441.x] [Citation(s) in RCA: 236] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Drug hypersensitivity reactions can occur with most drugs, are unpredictable, may affect any organ or system, and range widely in clinical severity from mild pruritus to anaphylaxis. In most cases, the suspected drug is avoided in the future. However, for certain patients, the particular drug may be essential for optimal therapy. Under these circumstances, desensitization may be performed. Drug desensitization is defined as the induction of a temporary state of tolerance of a compound responsible for a hypersensitivity reaction. It is performed by administering increasing doses of the medication concerned over a short period of time (from several hours to a few days) until the total cumulative therapeutic dose is achieved and tolerated. It is a high-risk procedure used only in patients in whom alternatives are less effective or not available after a positive risk/benefit analysis. Desensitization protocols have been developed and are used in patients with allergic reactions to antibiotics (mainly penicillin), insulins, sulfonamides, chemotherapeutic and biologic agents, and many other drugs. Desensitization is mainly performed in IgE-mediated reactions, but also in reactions where drug-specific IgE have not been demonstrated. Desensitization induces a temporary tolerant state, which can only be maintained by continuous administration of the medication. Thus, for treatments like chemotherapy, which have an average interval of 4 weeks between cycles, the procedure must be repeated for every new course. In this paper, some background information on rapid desensitization procedures is provided. We define the drugs and drug reactions indicated for such procedures, describe the possible mechanism of action, and discuss the indications and contraindications. The data should serve as background information for a database (accessible via the EAACI-homepage) with standardized protocols for rapid desensitization for antibiotics, chemotherapeutic agents, monoclonal antibodies/fusion proteins, and other drugs.
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Affiliation(s)
- J R Cernadas
- Department of Allergy and Clinical Immunology, Medical University, H. S. João, Porto, Portugal.
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Tuboi M, Tsuchiya T, Taguchi R, Tanaka Y, Iwasaki Y, Hashimoto K, Kakizaki S, Okada S, Shimizu H, Mori M. [Insulin allergy whose local/systemic reactions were reduced by desensitization with long-acting insulin analog, glargine]. ACTA ACUST UNITED AC 2010; 99:133-5. [PMID: 20196485 DOI: 10.2169/naika.99.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Miki Tuboi
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi
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Affiliation(s)
- Nobuaki Ozaki
- From the Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yutaka Oiso
- From the Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lassmann-Vague V, Clavel S, Guerci B, Hanaire H, Leroy R, Loeuille G, Mantovani I, Pinget M, Renard E, Tubiana-Rufi N. When to treat a diabetic patient using an external insulin pump. Expert consensus. Société francophone du diabète (ex ALFEDIAM) 2009. DIABETES & METABOLISM 2010; 36:79-85. [DOI: 10.1016/j.diabet.2009.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 09/22/2009] [Accepted: 09/26/2009] [Indexed: 10/20/2022]
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Akinci B, Yener S, Bayraktar F, Yesil S. Allergic reactions to human insulin: a review of current knowledge and treatment options. Endocrine 2010; 37:33-9. [PMID: 19876775 DOI: 10.1007/s12020-009-9256-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 10/11/2009] [Indexed: 01/29/2023]
Abstract
Although the incidence of insulin allergy decreased after the introduction of recombinant human insulin preparations, it is still a major problem which may be life-threatening in some cases. In this article, we attempted to review current knowledge concerning allergic reactions to human insulin and discuss the available treatment options of insulin allergy.
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Affiliation(s)
- Baris Akinci
- Division of Endocrinology of Metabolism, Department of Internal Medicine, Dokuz Eylul University Medical School, Inciralti, 35340 Izmir, Turkey.
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Holstein A, Stege H, Kovacs P. Lipoatrophy associated with the use of insulin analogues: a new case associated with the use of insulin glargine and review of the literature. Expert Opin Drug Saf 2009; 9:225-31. [DOI: 10.1517/14740330903496402] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Andreas Holstein
- Lippe-Detmold Clinic, 1st Department of Medicine, Röntgenstr. 18, Detmold, D-32756, Germany ;
| | - Helger Stege
- Lippe-Detmold Clinic, Department of Dermatology, Röntgenstr. 18, Detmold, D-32756, Germany
| | - Peter Kovacs
- University of Leipzig, Interdisciplinary Centre for Clinical Research, Inselstraße 22, Leipzig, 04103, Germany
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Radermecker RP, Renard E, Scheen AJ. Circulating insulin antibodies: influence of continuous subcutaneous or intraperitoneal insulin infusion, and impact on glucose control. Diabetes Metab Res Rev 2009; 25:491-501. [PMID: 19496088 DOI: 10.1002/dmrr.961] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The purification of animal insulin preparations and the use of human recombinant insulin have markedly reduced the incidence, but not completely suppressed, the development of anti-insulin antibodies (IAs). Advances in technologies concerning the mode of delivery of insulin, i.e. continuous subcutaneous insulin infusion (CSII), continuous peritoneal insulin infusion (CPII) and more recently inhaled insulin administration, appear to significantly increase circulating levels of immunoglobulin G (IgG) anti-IAs in diabetic patients. However, the increase is usually moderate and mostly transient as compared to previous observations with poorly purified animal insulin preparations. The clinical impact of these circulating anti-IAs remains unclear. Nevertheless, several studies have suggested that antibodies could retard insulin action, leading to a worsening of postprandial hyperglycaemia and/or serve as a carrier, thus leading to unexpected hypoglycaemia. CPII may be associated with more marked and sustained increase in IAs levels, possibly related to the use of an unstable insulin and the formation of immunogenic aggregates of insulin. The possible clinical consequences of these high levels of IAs remain to be evaluated because a low-glucose morning syndrome or severe insulin resistance with ketone bodies production have been reported in some cases. In conclusion, even if CSII and CPII may promote the development of circulating IAs, this increase does not lead to immunological insulin resistance, compared to that previously described with animal non-purified insulin preparations, and seems to have only marginal influence on blood glucose control or complications in most diabetic patients.
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Affiliation(s)
- R P Radermecker
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, Liège, Belgium.
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45
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Hara M, Izumida Y, Sato N, Ohashi K, Osuga JI, Tobe K, Tsukamoto K, Kadowaki T. Successful desensitization by glargine administration in a patient with insulin allergy: a case report. Diabetes Res Clin Pract 2009; 84:e48-9. [PMID: 19286270 DOI: 10.1016/j.diabres.2009.02.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2009] [Revised: 01/17/2009] [Accepted: 02/13/2009] [Indexed: 02/08/2023]
Abstract
The patient was a 56-year-old man with type 2 diabetes and insulin allergy. He was administered glargine, which did not produce any allergic reactions, except for a small non-pruritic wheal. Thereafter, other insulin preparation could be administered. We consider this the first case of successful insulin desensitization by glargine administration.
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Affiliation(s)
- Masumi Hara
- Department of Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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46
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Goykhman S, Drincic A, Desmangles JC, Rendell M. Insulin Glargine: a review 8 years after its introduction. Expert Opin Pharmacother 2009; 10:705-18. [PMID: 19284367 DOI: 10.1517/14656560902775677] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Insulin Glargine was the first long-acting insulin analog produced by recombinant DNA technology, approved for use by the US FDA in April 2000 and by the European Agency for the Evaluation of Medicinal Products in June, 2000. It has become the most widely used insulin in the USA owing to its long duration of action without a pronounced peak. The principal advantage of insulin Glargine over neutral protamine Hagedorn (NPH) insulin is in a lower frequency of hypoglycemic reactions, thus affording improved safety. It is used in both type 1 and type 2 diabetes, usually as a single daily dose. In type 2 patients, it is often the first insulin introduced as a single daily dose. Although insulin Glargine is typically administered as a single nighttime dose, it can be given in the morning or at any other time convenient for the patient. In labile type 1 diabetes, it is often most effective given as two daily injections. In obese, insulin-resistant patients, it may be best to administer insulin Glargine in two separate doses, owing to the high volumes of injected insulin required. Insulin Glargine does not treat postprandial hyperglycemia. It is necessary to supplement with short-acting insulin at mealtimes to control glucose surges after meals. Insulin Glargine is effective in hospitalized and postsurgical patients on account of its lack of pronounced insulin peaks and long duration of action. Although there is considerable use of Glargine in pregnant diabetic women, there is no definitive study to confirm its benefits. Insulin Glargine is thought to coprecipitate supplementary short-acting insulins when co-administered in the same syringe. Therefore, more injections are typically needed in the usual treatment regimen for insulin requiring diabetes. In many cases, constant basal insulin levels may be achieved with multiple overlapping doses of NPH insulin given together with short-acting insulin at mealtimes. Such a therapy may be less costly, but the major advantage of insulin Glargine remains the greater safety of a lower frequency of hypoglycemic reactions.
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Affiliation(s)
- Stanislav Goykhman
- Creighton University School of Medicine, Children's Hospital, Diabetes Center, Divisions of Adult and Pediatric Endocrinology, Omaha, NE 68131, USA
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Bruttomesso D, Costa S, Baritussio A. Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy. Diabetes Metab Res Rev 2009; 25:99-111. [PMID: 19172576 DOI: 10.1002/dmrr.931] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Thirty years after its introduction, the use of continuous subcutaneous insulin infusion (CSII) keeps increasing, especially among children and adolescents. The technique, when used properly, is safe and effective.Compared with traditional NPH-based multiple daily injections (MDI), CSII provides a small but clinically important reduction of HbA(1c) levels, diminishes blood glucose variability, decreases severe hypoglycaemic episodes and offers a better way to cope with the dawn phenomenon.Insulin analogues have improved the treatment of diabetes, eroding part of the place previously occupied by CSII, but CSII still remains the first option for patients experiencing severe hypoglycaemic episodes, high HbA(1c) values or marked glucose variability while being treated with optimized MDI. Furthermore CSII is better than MDI considering the effects on quality of life and the possibility to adjust insulin administration according to physical activity or food intake.CSII may be limited by cost. Present estimates suggest that CSII may be cost-effective just for patients experiencing a marked improvement in HbA(1c) or a decrease in severe hypoglycaemic episodes, but the effects on quality of life are difficult to measure.CSII does not merely imply wearing an external device; it requires a multidisciplinary team, intensive patient education and continuous follow up.
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Affiliation(s)
- Daniela Bruttomesso
- Department of Clinical and Experimental Medicine, Division of Metabolic Diseases, University of Padova, Padova, Italy.
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Mollar-Puchades MA, Villanueva IL. Insulin glulisine in the treatment of allergy to rapid acting insulin and its rapid acting analogs. Diabetes Res Clin Pract 2009; 83:e21-2. [PMID: 19070911 DOI: 10.1016/j.diabres.2008.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Revised: 06/15/2008] [Accepted: 11/05/2008] [Indexed: 02/08/2023]
Abstract
This is a case report of a patient with allergy to the rapid acting insulins and rapid acting analogs. Before trying insulin desensitization the treatment was changed to a basal-bolus regimen with glargine and glulisine with no signs of insulin allergy during the months after the start of the treatment.
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Affiliation(s)
- M A Mollar-Puchades
- Department of Endocrinology, Specialty Care Center Jaume I, Castellon de la Plana, Spain.
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Neville KA, Verge CF, Wainstein BK, Woodhead HJ, Ziegler JB, Walker JL. Insulin allergy desensitization with simultaneous intravenous insulin and continuous subcutaneous insulin infusion. Pediatr Diabetes 2008; 9:420-2. [PMID: 18775000 DOI: 10.1111/j.1399-5448.2008.00348.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Persistent 'IgE-mediated' insulin allergy (type 1 allergy) (1), unresponsive to changes in insulin type or the use of antihistamines, necessitates desensitization. A number of case reports (2-7) and recent reviews (8, 9) have demonstrated that desensitization can be achieved with continuous subcutaneous insulin infusion (CSII), but in type 1 diabetes mellitus, the need to slowly increase insulin dose from sub-therapeutic levels competes with the need for glycaemic control and suppression of ketogenesis. Tolerance to intravenous (IV) insulin despite persistent life-threatening allergic reactions to subcutaneous human insulin (bolus or CSII) has been recently described (10). We present the cases of two unrelated 9-yr-old boys with persistent generalized urticarial reactions to subcutaneous injections of all available insulin types, despite treatment with oral antihistamines. After failed rapid desensitization to insulin delivered by either subcutaneous injection or CSII, the concurrent use of IV insulin allowed desensitization to CSII over 5-6 d.
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Affiliation(s)
- Kristen A Neville
- Department of Endocrinology, Sydney Children's Hospital, New South Wales, Australia.
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Heinzerling L, Raile K, Rochlitz H, Zuberbier T, Worm M. Insulin allergy: clinical manifestations and management strategies. Allergy 2008; 63:148-55. [PMID: 18186805 DOI: 10.1111/j.1398-9995.2007.01567.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Insulin allergy in patients with diabetes mellitus on insulin treatment is a rare condition. It is suspected upon noticing immediate symptoms following insulin injections. The immediate vital implications for the patient call for prompt diagnosis and management of insulin allergy. We review current knowledge and procedures based on four diabetic patients who presented in our clinic. Insulin allergy was suspected as they showed immediate symptoms after insulin injection (urticaria, rash, angioedema, hypotension, dyspnea). A detailed allergologic work-up was performed and adequate therapy was initiated. In three of the four patients, a specific immunotherapy was started whereas in one patient a switch to oral antidiabetics was possible and consequently initiated. By standard prick testing and measurement of specific IgE antibodies, a type 1 IgE-mediated allergy was confirmed. After initiation of insulin immunotherapy, the symptoms completely resolved in two out three of patients and significantly improved in the third patient. The fourth patient was successfully switched to oral antidiabetics. Insulin allergy is a rare but severe condition that calls for immediate allergological work-up. It can be managed well in close cooperation between the diabetologist and the allergologist. Specific immunotherapy is efficient and should be considered.
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Affiliation(s)
- L Heinzerling
- Department of Dermatology and Allergy, Charité Universitätsmedizin, Berlin, Germany
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