Diabetes and hypoglycemia due to insulin antibodies

Nickel-gold bimetallic monolayer colloidal crystals fabricated via galvanic replacement as a highly sensitive electrochemical sensor

Bimetallic Ni-Au monolayer colloidal crystals (MCCs) were fabricated by galvanic replacement of Ni monolayers with Au salt. The influence of Au concentration used in the galvanic replacement solutions on the morphology and structure of the resulting Ni-Au surface is studied. It was found that the use of monolayer colloidal crystals, which display cohesive structure formations across the monolayer, results in the galvanic replacement reaction occurring more evenly over the surface when compared to the thin film counterpart. The fabricated devices were analyzed under alkaline conditions using chronoamperometric techniques to detect glucose concentrations ranging between 20 μM and 10 mM. The optimum Ni-Au MCC substrate was produced using 0.1 mM Au salt solution and showed a very low experimental detection limit of 14.9 μM and a calculated sensitivity of 506 μA mM^-1 cm^-2, which was ∼3 times larger than that of the plain Ni MCC substrate. The Ni-Au MCC substrate also showed minimal current response changes in the presence of common physiological contaminants, thus being a highly selective electrochemical glucose sensor.

The insulin autoimmune syndrome (IAS) as a cause of hypoglycaemia: an update on the pathophysiology, biochemical investigations and diagnosis

Insulin autoimmune syndrome (IAS) is considered to be very rare in Caucasians. Understanding its pathophysiology is paramount in (a) appreciating its potential impact on analyses of pancreatic hormones and (b) explaining its highly variable clinical manifestations in non-diabetic, non-acutely ill patients with indeterminate hypoglycaemia. The underlying aetiology of IAS is the presence of variable affinity/avidity endogenous insulin antibodies in significant amounts. The two types of insulin antibodies namely antibodies which bind insulin and/or proinsulin(s) and receptor antibodies (insulin mimetic) will be discussed. Their biochemical and immunological roles in causing hypoglycaemia will be highlighted. Clinical manifestations of IAS can vary from mild and transient to spontaneous, severe and protracted hypoglycaemia necessitating in extreme cases plasmapheresis for glycaemic control. Antibodies of IAS can interfere in pancreatic immunoassay tests causing erroneous and potentially misleading results. Thorough testing for endogenous insulin antibodies must be considered in the investigations of non-diabetic, non-acutely ill patients with indeterminate and/or unexplained hypoglycaemia.

Severe insulin resistance due to anti-insulin antibodies: response to plasma exchange and immunosuppressive therapy

Anti-insulin antibodies have been described in two contexts: in insulin-naive individuals (so-called 'insulin autoimmune syndrome') and in patients with insulin-treated diabetes, in whom antibodies are rarely of clinical significance. We report the case of an 68-year-old woman who exhibited a local allergic reaction to subcutaneous insulin followed by severe insulin resistance, evidenced by poor glycaemic control despite treatment with > 3.5 U/kg of insulin per day. She was found to have circulating polyclonal anti-insulin antibodies of the IgG subtype and responded clinically to a course of plasma exchange and immunosuppression with mycophenolate mofetil and, subsequently, intravenous immunoglobulin. Falling titres of antibodies on this regimen correlated with improved glycaemic control. This case suggests that clinicians should be alert to the possibility of insulin resistance due to anti-insulin antibodies and that immunosuppression in this situation may be a valuable therapeutic option.

The management of insulinoma

BACKGROUND

Insulinomas are rare tumours. Their clinical presentation, localization techniques and operative management were reviewed.

METHODS

An electronic search of the Medline, Embase and Cochrane databases was undertaken for articles published between January 1966 and June 2005 on the history, presentation, clinical evaluation, use of imaging techniques for tumour localization and operative management of insulinoma.

RESULTS AND CONCLUSION

Most insulinomas are intrapancreatic, benign and solitary. Biochemical diagnosis is obtained during a supervised 72-h fast. Non-invasive preoperative imaging techniques to localize lesions continue to evolve. Intraoperative ultrasonography can be combined with other preoperative imaging modalities to improve tumour detection. Surgical resection is the treatment of choice. In the absence of preoperative localization and intraoperative detection of an insulinoma, blind pancreatic resection is not recommended.

High-performance liquid chromatographic determination of insulin in rat and human plasma

A rapid and simple isocratic chromatographic procedure for the determination of insulin in human and rat plasma using reversed-phase (RP) high-performance liquid chromatography with an ultraviolet/visible detector is described. The method includes extraction of insulin from human and rat plasma into dichloromethane, followed by back-extraction into 0.05 N hydrochloric acid. The organic phase was evaporated under a stream of nitrogen. The aqueous phase was filtered and a 100 microliters aliquot was analyzed on a RP-C18 column eluted with a mobile phase consisting of a mixture of 74 vol of 0.2 M sodium sulfate anhydrous adjusted to pH 2.3 with phosphoric acid and 26 vol of acetonitrile. The flow rate was 1.2 ml/min and the wavelength was set at 214 nm. The calibration curve was linear over the range of 75-800 microIU/ml. The precision of the assay expressed as coefficients of variation was less than 6% over the entire concentration range. The recovery for insulin ranged from 79 to 81% from human and rat plasma, with coefficients of variation less than 6%. The intra- and interassay coefficients of variation were less than 5.7%. The limit of detection was 50 microIU/ml.

Imaging of the buffering effect of insulin antibodies in the autoimmune hypoglycemic syndrome

Insulin autoimmune hypoglycemia is characterized by recurrent hypoglycemia and high levels of immunoreactive insulin in the presence of insulin autoantibodies. The mechanisms inducing hypoglycemia are largely unknown. An [123I]insulin scintigraphic scanning was performed to directly demonstrate the effect of antibodies on insulin biodistribution in one patient with this syndrome both before and after treatment. The patient had insulin autoantibodies IgG3 lambda, which had a single site dissociation constant (Kd = 10(-7) mol/L, by Scatchard analysis), a very fast dissociation rate of immune complexes, and a very rapid association of [125I]insulin. Insulin receptors on red blood cells were down-regulated. The [123I]insulin scintigraphic study imaged the buffering effect of antibodies on insulin bioavailability. [123I]Insulin was not removed from the blood, and no liver or kidney uptake of the hormone occurred. The frequency and severity of hypoglycemic episodes required treatment. Insulin antibody levels decreased and [123I]insulin biodistribution improved after treatment with plasmapheresis and prednisone. Improved hormone bioavailability was further evidenced by the reduction in the hypoglycemic delay after i.v. insulin from 90 min before any treatment to 60 min after plasmapheresis and 30 min after steroid administration. Glucose tolerance was normal after treatment. Plasmapheresis followed by steroid treatment can lower the insulin antibody concentration, abolish severe hypoglycemia, and improve insulin biodistribution and glucose tolerance in insulin autoimmune hypoglycemia.

Insulin antibodies and hypoglycemia in diabetic patients. Can a quantitative analysis of antibody binding predict the risk of hypoglycemia?

We report a noninsulin-dependent diabetes mellitus (NIDDM) patient with spontaneous, severe hypoglycemic reactions and the presence of insulin antibodies. He had a remote antecedent history of beef-pork insulin therapy as well as exposure to hydralazine. Detailed insulin binding kinetic studies were performed in this patient as well as in six other insulin-treated diabetic patients with anti-insulin antibodies (three with and three without an obvious cause of hypoglycemia). Sera from the current patient and five of the six other diabetic patients (one NIDDM, four IDDM) revealed two types of binding sites: high-affinity with low capacity (Kd, 0.4-12.4 x 10(-9) mol/L; binding capacity, 0.6-659 mU/L) and low-affinity with high capacity (Kd, 0.3 to 35.7 x 10(-7) mol/L; binding capacity; 202-113,680 mU/L). One NIDDM patient had only high-affinity antibodies (Kd, 22.9 x 10(-9) mol/L; binding capacity of 78 mU/L). Type of diabetes mellitus, insulin antibody titers or their binding capacities, insulin levels (total, bound, or free), and bioavailable insulin were not related to hypoglycemic reactions. Two calculated values by the method described tended to discriminate patients with and without hypoglycemia. The calculated amount of low-affinity antibody bound insulin ranged from 69.4-2090 mU/L vs < 4-70.6 mU/L in patients with and without hypoglycemia, respectively. The best discrimination was afford by the percent saturation of low-affinity binding sites; values were clearly higher in the patients with hypoglycemia (2.5-34.4%) than in those without hypoglycemia (not detectable, 0.06, 0.15%). Consideration of the possible drug-associated insulin antibody formation in insulin-treated diabetics and the novel quantitative analysis of the antibody binding kinetics should prove helpful in evaluating patients with high insulin antibody titers and assessing the risk of hypoglycemia.

Reactive hypoglycemic coma due to insulin autoimmune syndrome: case report and literature review

Recurrent episodes of postprandial hypoglycemic symptoms culminated in hypoglycemic coma in a hypertensive but otherwise healthy man while he was taking hydralazine. The patient was found to have an extreme elevation in the immunoreactive insulin level, leading to the discovery of insulin antibodies in the absence of prior exposure to exogenous insulin. Negative results of an anatomic study of the pancreas and an inability to reproduce hypoglycemia during a prolonged fast helped to exclude insulinoma. In contrast, symptomatic hypoglycemia developed in response to oral glucose loading and was associated with an elevation in total and free insulin as well as C-peptide levels. The patient was diagnosed with insulin autoimmune syndrome, which, although a common source of hypoglycemia in Japan, has been well documented in only 15 cases from other countries. HLA typing revealed the patient to be positive for groups Cw4 and DR4, a combination that has been preliminarily associated with insulin autoimmune syndrome in Japan. Unlike the majority of cases previously reported, this patient had no clinical or serologic evidence of an underlying autoimmune disorder and had not been exposed to drugs containing sulfhydryl groups. This case adds to the world literature on insulin autoimmune syndrome, lends support to a postulated HLA association, and documents the presence of insulin autoantibodies in the absence of another underlying autoimmune disorder.

Insulin autoimmune syndrome is the third leading cause of spontaneous hypoglycemic attacks in Japan

From 1979 to 1981, questionnaires were sent to 2094 hospitals throughout Japan to investigate the causes of severe hypoglycemic attacks other than the administration of oral hypoglycemic agents or insulin preparations. The survey revealed three main causes for the attacks, of which the first was insulinoma, the second extrapancreatic neoplasms, and the third was insulin autoimmune syndrome (IAS), in descending order. Seven years later, a second survey was carried out, which showed the order of the three disorders as the cause of the hypoglycemic attacks to be the same as in the first survey. In both studies it was suggested that the IAS was frequently induced by thiol compounds.

Insulin autoantibodies in Graves' disease--before and after carbimazole therapy

Insulin autoantibodies (IAA) are well documented in patients with insulin-dependent diabetes (IDDM) prior to the administration of insulin and in patients with reactive hypoglycaemia--the insulin autoimmune syndrome (IAS). It has been suggested that IAA can be induced by the administration of drugs containing sulphydryl groups, such as carbimazole, and they have been frequently described in Graves' disease. An alternative explanation is the clustering of autoantibodies in autoimmune disease. We studied 39 patients (37 females, two males, age range 14 to 61 years; mean 33.8 years) with proven Graves' disease and no previous treatment with carbimazole. Fifteen of the 39 patients had a family history of other autoimmune diseases. IAA and thyroid autoantibodies were assayed at diagnosis and monthly thereafter while on treatment with carbimazole, for up to 6 months. IAA were measured using a direct-binding solid-phase ELISA and specificity was confirmed by absorption studies using insulin covalently coupled to Sepharose beads. At diagnosis 33 of the 39 patients (85%) were positive for thyroid microsomal antibodies, 13 (33%) were positive for thyroglobulin antibodies, and 4 (10%) were positive for IAA. All IAA-positive patients had microsomal antibodies at diagnosis, and two had thyroglobulin antibodies in addition. After 4 months on carbimazole, the frequency of thyroid microsomal autoantibodies was unchanged (83%), while that of anti-thyroglobulin antibodies had fallen (8.6%). All four IAA-positive patients remained positive, and studies of binding to human, porcine and bovine insulin demonstrated that one serum, initially human insulin specific, later became cross-reactive with all three. We conclude that low titres of IAA are found in Graves' disease, and are associated with the presence of autoimmunity rather than the carbimazole. Symptomatic hypoglycaemia, however, is rare in Caucasian patients.

Autoimmune insulin syndrome

Initially described in Japan, the autoimmune insulin syndrome is caused by the presence of anti-insulin antibodies in patients who have never received insulin. This syndrome accounts for spontaneous or reactive hypoglycaemia with very high levels of total immuno-reactive insulin. Discordance between the levels of immunoreactive insulin and C peptide indicate the possible presence of anti-insulin antibodies; this can avoid an incorrect diagnosis of insulinoma. These autoimmune hypoglycaemias often present a difficult diagnostic problem in distinguishing them from factitious hypoglycaemia. The course of the autoimmune insulin syndrome is usually favourable, with a spontaneous rapid diminution of the levels of anti-insulin antibodies. The reasons for the appearance of anti-insulin antibodies and the exact mechanisms of the hypoglycaemia remain uncertain. However, the frequent association of the autoimmune insulin syndrome with certain autoimmune diseases suggest a common immune dysfunction. Drugs containing a sulphydryl group have been implicated in the aetiology of this syndrome.

Autoantibodies to the insulin receptor as a cause of autoimmune hypoglycemia in systemic lupus erythematosus

A 52-year-old black woman presented with clinical features of systemic lupus erythematosus (SLE) and severe fasting hypoglycemia. Hypoglycemia was secondary to autoantibodies to the insulin receptor that were detected in the patient's serum. There were no anti-insulin antibodies, and other causes of hypoglycemia were excluded. Treatment with high-dose glucocorticoids resulted in restoration of euglycemia associated with resolution of circulating anti-receptor antibodies and parallel improvement in clinical and laboratory features of SLE. This case is compared with other cases of autoimmune hypoglycemia due to anti-receptor antibodies.

Insulin autoimmune syndrome with insulin-resistant diabetes at the incipient stage prior to hypoglycemic attacks

Insulin autoimmune syndrome is characterized by spontaneous hypoglycemia, glucose intolerance, hyperinsulinemia and insulin-binding antibodies in serum without previous immunization. A 31-year-old man with Graves' disease developed insulin autoantibodies after therapy with methimazole. The patient was unique in that persistent hyperglycemia with polyuria and polydipsia had continued for several days before frequent hypoglycemic attacks appeared. We were able to extract a huge amount of immunoreactive insulin (116,000 microU/ml) with acid-ethanol from his serum obtained in the diabetic stage, and serum C-peptide immunoreactivity was as high as 268 ng/ml. The insulin-binding activity of his serum was quite potent, and when 1:5,000 diluted serum was incubated with 125I-porcine insulin, 71.2% of the label could be precipitated by polyethylene glycol. The insulin-binding protein was identified as mainly IgG with kappa light chains. Insulin-binding activity was not detected in serum obtained before methimazole therapy, suggesting that the drug was responsible for the induction of antibodies in this patient. The antibodies recognized porcine, sheep, bovine and horse insulins as well as human insulin. The mechanisms by which the antibodies produced hyper- and hypoglycemia have also been discussed.

Comparison of liquid phase radiobinding assay and solid phase ELISA for the measurement of insulin antibodies and insulin autoantibodies in serum

Sera containing insulin antibodies from 20 insulin-treated diabetic patients, sera containing insulin autoantibodies from 20 insulin-naive non-diabetic patients, and from 10 normal controls, were tested at 1:20 dilution in three different radioimmunoassays (RIA) and an enzyme linked immunosorbent assay (ELISA), using a highly purified human insulin ligand. The RIA using insulin radiolabelled at multiple sites detected insulin antibodies in 17/20 and insulin autoantibodies in 13/20 sera. The same RIA using A-14-monoiodinated insulin was sensitive to antibodies and autoantibodies in all the sera. The same RIA using sera after insulin extraction detected only 13/20 diabetic sera and 9/20 autoimmune sera as positive, owing to a substantial rise in non-specific binding of the control sera. ELISA was sensitive to insulin antibodies and autoantibodies in every case. When binding curves for ELISA and the most sensitive RIA were compared using serial dilutions of four insulin antibody containing sera and four insulin autoantibody containing sera, antibody titres varied from 1.1 to 3.8 times higher in ELISA, and autoantibody titres from 10.6 to 28.6 times higher in ELISA. These studies indicate that ELISA is more sensitive than RIA to insulin antibodies, and in particular to insulin autoantibodies.

Monoclonal gammopathy with an insulin binding IgG(K) M-component, associated with severe hypoglycaemia

A case is described in which a monoclonal gammopathy was associated with postprandial hypoglycaemia, resulting from insulin binding by the M-component. The monoclonal immunoglobulin possessed a low affinity for insulin, but its binding capacity was very high. Cytotoxic chemotherapy and diazoxide treatment failed to prevent severe hypoglycaemic attacks.

Pathogenetic mechanisms of hereditary diabetes mellitus

Novel laboratory techniques such as the determination of proinsulin, insulin, C-peptide and insulin receptors have allowed further subclassification of diabetes mellitus today as representing a symptom rather than a disease. Numerous pathogenetic mechanisms of diabetes have been identified, many of these being genetically determined and this may extend possibilities for genetic counselling. As a geneticist's view, the pathogenetic concept of diabetes presented here is mostly confined to genetic mechanisms, leaving aside other influences on the development of diabetes such as hormones, viruses, nutrition and drugs. Mendelian inherited diabetic disorders are related to different pathogenetic principles where possible, being speculative in some cases.

Preparation and in vitro evaluation of a new extracorporeal dialyzer with immobilized insulin

A specific extracorporeal immunoadsorbent system has been developed that has potential application for the treatment of complications related to the presence of plasma insulin antibodies, namely severe insulin resistance and autoimmune hypoglycemia. The immunoadsorbent system described here makes use of a commercially available cellulose-based, hollow-fiber hemodialyzer. Optimal conditions for the coupling of insulin to cellulose matrices were found to involve activation with 1,4-butanediol diglycidyl ether and reaction with insulin at pH 7.4. The insulin-dialyzer prepared under these conditions contained 35.5 mg to 37.9 mg of insulin which correspond to a theoretical binding capacity of 887.5 to 947.5 units of insulin. Recirculation of human plasma with high insulin antibody titers through the insulin-dialyzer resulted in the clearance of 82-99% and 50-83% of high affinity and total insulin antibodies, respectively. The clearance of insulin antibodies approached a steady state after 15 minutes of recirculation at a flow rate of 50 ml/min. Regeneration of used insulin-dialyzers was accomplished by treatment with 0.02 M citrate buffer pH 3.2, which restored their ability to clear 90% and 40% of high affinity and total insulin antibodies, respectively. The principle of the insulin-dialyzer may find application in other disease states where removal of specific antibodies or other high molecular weight species may be of therapeutic value.

Insulin resistance and monoclonal gammopathy

Two maturity-onset diabetic patients developed severe insulin resistance during the course of monoclonal gammopathies. One patient had Waldenström macroglobulinemia and the other had multiple myeloma with IgA gammopathy. The maximum insulin binding capacity (MIBC) was 121 U/liter and 54.7 U/liter, respectively, during insulin resistance. The clinical courses of insulin resistance paralleled the activity of the monoclonal gammopathies (MG) with the insulin resistance disappearing after the monoclonal gammopathies were controlled. Six other diabetic patients with concurrent insulin resistance and monoclonal gammopathies are reviewed.