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Meredith RR, Patel P, Huang P, Onyenekwu CP, Rai H, Tversky J, Alvarez-Arango S. A case report and systematic literature review: insulin-induced type III hypersensitivity reaction. FRONTIERS IN ALLERGY 2024; 5:1357901. [PMID: 38469413 PMCID: PMC10926194 DOI: 10.3389/falgy.2024.1357901] [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: 12/18/2023] [Accepted: 02/09/2024] [Indexed: 03/13/2024] Open
Abstract
Insulin-induced type III hypersensitivity reactions (HSRs) are exceedingly rare and pose complex diagnostic and management challenges. We describe a case of a 43-year-old woman with type 1 diabetes mellitus (DM), severe insulin resistance, and subcutaneous nodules at injection sites, accompanied by elevated anti-insulin IgG autoantibodies. Treatment involved therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIg) as bridge therapy, followed by long-term immunosuppression, which reduced autoantibody levels and improved insulin tolerance. Given the limited treatment guidelines, we conducted a comprehensive literature review, identifying 16 similar cases. Most patients were females with a median age of 36.5 years; 63% had type 1 DM, and 44% had concurrent insulin resistance (56% with elevated autoantibodies). Treatment approaches varied, with glucocorticoids used in 67% of cases. Patients with type 1 DM were less responsive to steroids than those with type 2 DM, and had a more severe course. Of those patients with severe disease necessitating immunosuppression, 66% had poor responses or experienced relapses. The underlying mechanism of insulin-induced type III HSRs remains poorly understood. Immunosuppressive therapy reduces anti-insulin IgG autoantibodies, leading to short-term clinical improvement and improved insulin resistance, emphasizing their crucial role in the condition. However, the long-term efficacy of immunosuppression remains uncertain and necessitates continuous evaluation and further research.
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Affiliation(s)
- Rebecca R. Meredith
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Pooja Patel
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Polly Huang
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chinelo Pamela Onyenekwu
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Herleen Rai
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jody Tversky
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Santiago Alvarez-Arango
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Clinical Pharmacology, Department of Medicine and Pharmacology and Molecular Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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2
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Alkhatib EH, Grundman JB, Adamusiak AM, Bellin MD, Brooks JP, Buckley KS, Janssen EM, Kitcharoensakkul M, McNerney KP, Pfeifer TL, Polk BI, Marks BE. Case Report: Insulin hypersensitivity in youth with type 1 diabetes. Front Endocrinol (Lausanne) 2023; 14:1226231. [PMID: 37929017 PMCID: PMC10624121 DOI: 10.3389/fendo.2023.1226231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Objective Immediate type I, type III, and delayed type IV hypersensitivity reactions to insulin are rare, but potentially serious complications of exogenous insulin administration required for the treatment of type 1 diabetes (T1D). Methods We present four cases of insulin hypersensitivity reactions occurring in youth with T1D and a literature review of this topic. Results Insulin hypersensitivity reactions included types I, III, and IV with presentations ranging from localized urticaria, erythematous nodules, and eczematous plaques to anaphylaxis with respiratory distress. Reactions occurred in youth with newly diagnosed T1D and in those with long-standing T1D who were using both injection and insulin pump therapy. Multidisciplinary care involving pediatric endocrinology and allergy/immunology utilizing trials of many adjunct therapies yielded minimal improvement. Despite the use of various treatments, including antihistamines, topical therapies, immunosuppressant medications, desensitization trials, and intravenous immune globulin, cutaneous reactions, elevated hemoglobin A1c levels, and negative effects on quality of life remain persistent challenges. One patient became one of the youngest pancreas transplant recipients in the world at age 12 years due to uncontrollable symptoms and intolerable adverse effects of attempted therapies. Conclusion Although rare, insulin hypersensitivity reactions negatively affect glycemic control and quality of life. These cases demonstrate the varying severity and presentation of insulin hypersensitivity reactions along with the limited success of various treatment approaches. Given the life-sustaining nature of insulin therapy, further studies are needed to better understand the underlying pathophysiology of insulin hypersensitivity and to develop targeted treatment approaches.
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Affiliation(s)
- Einas H. Alkhatib
- Department of Pediatric Endocrinology, Children’s National Hospital, Washington, DC, United States
| | - Jody B. Grundman
- Department of Pediatric Endocrinology, Children’s National Hospital, Washington, DC, United States
| | - Anna M. Adamusiak
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Melena D. Bellin
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
- Department of Pediatrics, Division of Endocrinology, University of Minnesota, Minneapolis, MN, United States
| | - Joel P. Brooks
- Department of Allergy and Immunology, Columbia University/New York-Presbyterian, New York, NY, United States
| | - Kevin S. Buckley
- Departments of Hematology/Oncology and Infectious Disease, Atrium Health Levine Children’s Hospital, Concord, NC, United States
| | - Erin M. Janssen
- Department of Rheumatology, Mott Children’s Hospital/University of Michigan, Ann Arbor, MI, United States
| | - Maleewan Kitcharoensakkul
- Departments of Pediatric Allergy and Pulmonary Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kyle P. McNerney
- Department of Pediatric Endocrinology, Washington University School of Medicine, St. Louis, MO, United States
| | - Thea L. Pfeifer
- Department of Pediatric Endocrinology, Atrium Health Levine Children’s Hospital, Concord, NC, United States
| | - Brooke I. Polk
- Departments of Pediatric Allergy and Pulmonary Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Brynn E. Marks
- Department of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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AVCI MERDİN F, AYDEMİR AT, KORKMAZ FN, ŞAH ÜNAL FT, GÖKÇAY CANPOLAT A, ÖKTEM A, DEMİR Ö, ŞAHİN M, EMRAL R, ERDOĞAN MF, GÜLLÜ S, TONYUKUK GEDİK V, KOÇYİĞİT P, ÇORAPÇIOĞLU D. Evaluation of chronic pruritus and associated skin findings in patients with diabetes mellitus. Turk J Med Sci 2023; 53:1489-1497. [PMID: 38813039 PMCID: PMC10763738 DOI: 10.55730/1300-0144.5716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 10/26/2023] [Accepted: 09/09/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim To explore the dermatological lesions associated with chronic pruritus in patients who were followed up at our clinic for type 1 and type 2 diabetes mellitus (DM). Materials and methods The study population consisted of 249 patients with DM, who presented to the endocrinology clinic at Ankara University Faculty of Medicine between January 2022, and March 2022, regardless of whether they had reported experiencing pruritus symptoms. The visual analog scale and 5-D itch scale were used to determine the severity of itching in patients. Dermatological examination findings were also evaluated. Results Of the 249 patients with DM, mean duration since diabetes was diagnosed was 12 ± 9.2 [median 10 (0.3-46)] years, and the mean HbA1c levels were 8.1% ± 2.1%. Pruritus was detected in 77 (30.9%) patients and the mean duration of diabetes diagnosis was 13.4 ± 9.7 years. Examination of the microvascular and macrovascular complications showed that the incidence of retinopathy, nephropathy, neuropathy and peripheral arterial disease was 31.2% (p = 0.003), 31.2% (p = 0.005), 66.2% (p < 0.001) and 10.4% (p = 0.038), respectively, in the group with pruritus. These incidences were significantly higher in the group with pruritus than in those without pruritus. Dermatological examination showed that the most common condition was xerosis (64%), followed by fungal skin infection (16%) and bullous pemphigoid (8%). No skin findings were noted in 7% of patients who complained of itching. Conclusion Chronic pruritus may be associated with several factors such as poor glycemic control, high BMI and microvascular and macrovascular complications in patients with DM. Especially in patients with severe generalized pruritus who do not respond to standard antipruritic treatments, the use of DPP-4 inhibitors, a class of oral antidiabetic agents, should be questioned and all medications being used by the patient should be reviewed.
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Affiliation(s)
- Fatma AVCI MERDİN
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Ahmet Taha AYDEMİR
- Department of Dermatology and Venereal Diseases, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Fatma Nur KORKMAZ
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Fatma Tuğçe ŞAH ÜNAL
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Asena GÖKÇAY CANPOLAT
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Ayşe ÖKTEM
- Department of Dermatology and Venereal Diseases, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Özgür DEMİR
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Mustafa ŞAHİN
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Rıfat EMRAL
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Murat Faik ERDOĞAN
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Sevim GÜLLÜ
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Vedia TONYUKUK GEDİK
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Pelin KOÇYİĞİT
- Department of Dermatology and Venereal Diseases, Faculty of Medicine, Ankara University, Ankara,
Turkiye
| | - Demet ÇORAPÇIOĞLU
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara,
Turkiye
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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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Insulin Reactions: What Do You Do When Your Treatment's the Trigger? Can J Diabetes 2023; 47:190-192. [PMID: 36137870 DOI: 10.1016/j.jcjd.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/28/2022] [Accepted: 08/23/2022] [Indexed: 11/21/2022]
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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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He F, Xu LL, Li YX, Dong YX. Nursing a patient with latent autoimmune diabetes in adults with insulin-related lipodystrophy, allergy, and exogenous insulin autoimmune syndrome: A case report. World J Clin Cases 2022; 10:7163-7170. [PMID: 36051121 PMCID: PMC9297400 DOI: 10.12998/wjcc.v10.i20.7163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/30/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Latent autoimmune diabetes in adults (LADA) is a special type of type 1 diabetes mellitus. During the early stages, patients with LADA are treated with oral antidiabetics. However, insulin treatment is still required as islet function gradually declines. Once patients have developed insulin allergy, clinical treatment and nursing care become very challenging.
CASE SUMMARY Here, we report a case of LADA with insulin-related lipodystrophy, allergy, and exogenous insulin autoimmune syndrome during insulin treatment, thus making it very difficult to effectively control glucose levels with insulin. We attempted subcutaneous injection and an insulin pump to desensitize the patient’s response to insulin, and finally assisted the doctor to select the appropriate insulin treatment for the patient. We describe the management of this patient from a nursing viewpoint.
CONCLUSION We summarize the nursing experience of a case with complex insulin allergy requiring desensitization treatment. Our approach is very practical and can be applied to similar patients needing insulin desensitization.
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Affiliation(s)
- Fang He
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Ling-Ling Xu
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yu-Xiu Li
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Ya-Xiu Dong
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing 100730, China
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Soodhana Mohan D, Hebbal Nagarajappa V, Sathyanarayana SO, Srinivas SM, Palany R. Insulin Therapy: “When Saviour Turns Hostile”. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2022. [DOI: 10.1159/000522562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Insulin is the cornerstone of type 1 diabetes mellitus (T1DM) treatment. Insulin allergy in patients with T1DM on insulin is an uncommon problem that might manifest itself as immediate or delayed symptoms after injections. We present 2 cases: the first is a 17-year-old girl who was diagnosed with T1DM at the age of 14 and has had several skin lesions at injection sites over the past 2 months that have not responded to antibiotics. The second case involves a 4-year-old boy who was diagnosed with T1DM at the age of 15 months and had non-tender, erythematous, and indurated lesions. Insulin hypersensitivity was detected in both cases, thus newer analogues were administered instead of regular and isophane insulin, and the lesions dramatically reduced.
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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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Petricău C, Nedelea I, Deleanu D. Successful desensitization in a patient with hypersensitivity to multiple insulin preparations - case report. Med Pharm Rep 2021; 94:248-251. [PMID: 34013197 PMCID: PMC8118211 DOI: 10.15386/mpr-1643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022] Open
Abstract
Hypersensitivity to insulin has decreased substantially in the past three decades, since purified human insulin was introduced to replace heterogeneous porcine and bovine preparations. However, human insulin and its analogs still have immunogenic potential that may prove detrimental for hypersensitive insulin-dependent diabetics. In cases of anaphylactic reactions to insulin, rapid desensitization may be considered as a treatment strategy. We present the first case of successful insulin desensitization in Romania for an uncontrolled diabetic patient with type I hypersensitivity to multiple insulin analogs.
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Affiliation(s)
- Carina Petricău
- Allergy Outpatient Unit, Professor Doctor Octavian Fodor Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Romania
- Department of Allergology and Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Irena Nedelea
- Allergy Outpatient Unit, Professor Doctor Octavian Fodor Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Romania
- Department of Allergology and Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Diana Deleanu
- Allergy Outpatient Unit, Professor Doctor Octavian Fodor Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Romania
- Department of Allergology and Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Internal Medicine Department, Professor Doctor Octavian Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
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Xu X, Niu L, Liu Y, Pang M, Lu W, Xia C, Zhu Y, Yang B, Wang Q. Study on the mechanism of Gegen Qinlian Decoction for treating type II diabetes mellitus by integrating network pharmacology and pharmacological evaluation. JOURNAL OF ETHNOPHARMACOLOGY 2020; 262:113129. [PMID: 32730886 DOI: 10.1016/j.jep.2020.113129] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 06/13/2020] [Accepted: 06/20/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Gegen Qinlian Decoction (GQD) is a classic traditional Chinese medicine prescription that is widely used to clinically treat diabetes mellitus. It is composed of Pueraria lobata (Willd.) Ohwi (ge gen), Scutellaria baicalensis Georgi (huang qin), Coptidis chinensis Franch. (huang lian), and Glycyrrhiza uralensis Fisch. (gan cao). However, the active ingredients in GQD and their mechanism of action are unclear. AIM OF THE STUDY In this study, we aimed to verify the efficacy of GQD in improving insulin resistance (IR) in diabetic mice and used network pharmacology to identify potential targets and pathways underlying its mechanism of action. MATERIALS AND METHODS A mouse model of diabetes was created by feeding mice a high-fat diet followed by an intraperitoneal injection of streptozotocin. These type II diabetic mice were administered either a clinical dose or a high dose of GQD, after which blood glucose and serum insulin levels were measured to assess its effects on IR. Network pharmacology was used to construct a 'component-pathway-target' network to elucidate the likely targets and pathways modulated in common by GQD components. Furthermore, mRNA transcript levels and protein expression levels of oestrogen receptor alpha (ESR1) were determined. RESULTS The in vivo experiment showed that GQD markedly decreased blood glucose and increased serum insulin levels in type II diabetic mice. Network pharmacology and bioinformatics analysis indicated that GQD regulated 82 corresponding proteins and 59 relevant biological pathways associated with diabetes. One such target was ESR1, which was significantly decreased at both the mRNA and protein levels in diabetic mice, but whose levels were significantly increased by GQD treatment. CONCLUSIONS This project provides a scientific basis for understanding the effectiveness of multi-component, multi-target compound formulas, as well as a new strategy for investigating therapeutic drugs for type II diabetes and other diseases.
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Affiliation(s)
- Xinyi Xu
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China
| | - Lulu Niu
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China
| | - Yan Liu
- Key Laboratory of Chinese Materia Medica, Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Meilu Pang
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China
| | - Wanying Lu
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China
| | - Cong Xia
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China
| | - Yuxuan Zhu
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China
| | - Bingyou Yang
- Key Laboratory of Chinese Materia Medica, Heilongjiang University of Chinese Medicine, Harbin, 150040, China.
| | - Qi Wang
- Department of Medicinal Chemistry and Natural Medicine Chemistry, College of Pharmacy, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150081, China.
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12
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Kimura T, Fushimi Y, Hayashi H, Tatsumi F, Kanda-Kimura Y, Shimoda M, Hirukawa H, Sanada J, Obata A, Kohara K, Nakanishi S, Mune T, Kaku K, Kaneto H. Insulin allergy brought out 8 years after starting insulin therapy in a subject with type 1 diabetes mellitus. Acta Diabetol 2020; 57:1025-1026. [PMID: 32078040 DOI: 10.1007/s00592-020-01499-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/08/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Tomohiko Kimura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan.
| | - Yoshiro Fushimi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Hiroaki Hayashi
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Fuminori Tatsumi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Yukiko Kanda-Kimura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Masashi Shimoda
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Hidenori Hirukawa
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Junpei Sanada
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Atsushi Obata
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Kenji Kohara
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Shuhei Nakanishi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Tomoatsu Mune
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Hospital, Kawasaki Medical School, Okayama, Japan
| | - Hideaki Kaneto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Matsushima 577, Kurashiki, 701-0192, Japan
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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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Abstract
In principle the whole human proteome is available for the generation of recombinant proteins and glycoproteins that may serve as drugs (biologics). Endogenous human proteins and glycoproteins are structurally heterogeneous but are recognized as self by the immune system; however, recombinant protein and glycoprotein molecules are necessarily produced in heterologous systems and may include structural variants that are non-self and potentially immunogenic. The addition of human type oligosaccharides may be critical to function while the addition of non-human sugar residues can render biologics immunogenic. A particular concern is the structure of oligosaccharides attached by the hamster and murine cell lines that provide the dominant production platform. Critical structure and function properties that contribute to optimization of therapeutic potential are illustrated through recombinant erythropoietin and antibody therapeutics.
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Affiliation(s)
- Roy Jefferis
- Emeritus Professor, Institute of Immunology and Immunotherapy, University of Birmingham College of Medical and Dental Sciences, Birmingham B15 2TT
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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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Cutaneous Adverse Effects of Diabetes Mellitus Medications and Medical Devices: A Review. Am J Clin Dermatol 2019; 20:97-114. [PMID: 30361953 DOI: 10.1007/s40257-018-0400-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diabetes mellitus is one of the most prevalent chronic diseases in the USA. If uncontrolled, diabetes can lead to devastating complications. Diabetes medications and medical devices largely contribute to the significant financial expense that the disease inflicts on affected individuals and society. Alongside significant economic burden, there are numerous cutaneous adverse effects associated with diabetes medications and medical devices. Despite the large and increasing number of individuals living with diabetes and the wide use of the related medications and medical devices, there is limited literature that comprehensively documents their cutaneous adverse effects. These cutaneous adverse effects are significant as they can worsen glycemic control, increase disease distress, and may increase risk of associated complications. Thus, it is important that providers can recognize these cutaneous adverse effects, identify the culprit agents, and can properly manage them. In this article, we provide a critical review of the cutaneous adverse effects of medications and devices used in the management of diabetes and provide insight into risk factors and prevention and an overview of therapeutic management. An emphasis is placed on clinical recognition and treatment for use of the medical providers who, regardless of practice setting, will treat patients with diabetes.
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17
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Baghban Taraghdari Z, Imani R, Mohabatpour F. A Review on Bioengineering Approaches to Insulin Delivery: A Pharmaceutical and Engineering Perspective. Macromol Biosci 2019; 19:e1800458. [DOI: 10.1002/mabi.201800458] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Zahra Baghban Taraghdari
- Z. Baghban Taraghdari, Dr. R. Imani, F. MohabatpourDepartment of Biomedical EngineeringAmirkabir University of Technology Tehran 15875/4413 Iran
| | - Rana Imani
- Z. Baghban Taraghdari, Dr. R. Imani, F. MohabatpourDepartment of Biomedical EngineeringAmirkabir University of Technology Tehran 15875/4413 Iran
| | - Fatemeh Mohabatpour
- Z. Baghban Taraghdari, Dr. R. Imani, F. MohabatpourDepartment of Biomedical EngineeringAmirkabir University of Technology Tehran 15875/4413 Iran
- Division of Biomedical EngineeringUniversity of Saskatchewan Saskatoon S7N5A9 Canada
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18
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Jialal I, Singh R. Oral Pharmacotherapy as Alternative Treatment for Type 2 Diabetes Mellitus in a 61 Year Old Ethnic Filipino Man with Insulin Allergies. Lab Med 2019; 50:93-95. [PMID: 30124948 DOI: 10.1093/labmed/lmy049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Allergy to insulin occurs in approximately 2% of patients treated with insulin. However, major guidelines fail to emphasize this serious adverse effect. In this article, we report on a 61 year old ethnic Filipino man who developed urticaria and pruritus with a swollen tongue, which necessitated a visit to the emergency department. His clinical diagnosis was confirmed by a high titer of anti-insulin antibodies. His condition was successfully managed by discontinuing insulin and by treatment with oral hypoglycemic agents, with no additional adverse reactions. At the most recent follow-up visit, his antibody titer had fallen; however, that titer has not normalized. Also, the patient currently does not have uticaria.
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Affiliation(s)
| | - Richa Singh
- Section of Endocrinology, VA Medical Center, Mather, CA
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19
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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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20
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Bzowyckyj AS, Stahnke AM. Hypersensitivity reactions to human insulin analogs in insulin-naïve patients: a systematic review. Ther Adv Endocrinol Metab 2018; 9:53-65. [PMID: 29387334 PMCID: PMC5784467 DOI: 10.1177/2042018817745484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of this study was to raise awareness of hypersensitivity reactions to human insulin analogs (HIAs) in insulin-naïve patients and encourage consistent and detailed reporting of HIA reactions. DATA SOURCES A search of PubMed, MEDLINE and International Pharmaceutical Abstracts using the terms 'insulin' and 'hypersensitivity' was completed with English language, humans, and publication date after 1 January 1990 as limits. STUDY SELECTION AND DATA EXTRACTION The initial search identified 598 articles. These titles and abstracts were reviewed for relevance (e.g. mention of HIA) resulting in the exclusion of 477 articles. The full texts of the remaining titles were evaluated in addition to each article's references to identify additional reports meeting criteria (n = 14). Upon extensive review, 118 articles were excluded for not meeting prespecified inclusion criteria, resulting in 17 articles. DATA SYNTHESIS Evidence supporting hypersensitivity reactions to HIAs was variable, potentially due to a variety of causes (e.g. difficulty identifying a true case of hypersensitivity reaction to HIAs). Inconsistencies were noted for the identification, confirmatory testing, management, and reporting of these reactions. Management strategies included use of insulin desensitization protocols, antihistamines, steroids, immunosuppressant/immunomodulator therapies, conversion to noninsulin therapies, and pancreas transplantation. CONCLUSIONS Complete and consistent identification, evaluation, management, and reporting of these reactions is essential. Specific aspects of the patient's history should be reported, including previous insulin exposure, the specific HIAs used, duration of use prior to the reaction, a clear timeline of the reaction, and discussion of precipitating events or confounding factors.
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Affiliation(s)
- Andrew S. Bzowyckyj
- Department of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, USA
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21
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Mehta S, Oza V, Potashner R, Zamora P, Raisingani M, Shah B. Allergic and non-allergic skin reactions associated with growth hormone therapy: elucidation of causative agents. J Pediatr Endocrinol Metab 2018; 31:5-11. [PMID: 29197220 DOI: 10.1515/jpem-2017-0309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/30/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Allergic and non-allergic skin reactions to recombinant human growth hormone (rhGH) are uncommon and infrequently reported. However, physicians should be aware of these potential side effects to determine whether the reactions constitute true allergies and how to proceed with growth hormone therapy. To review allergic and non-allergic skin reactions caused by rhGH and subsequent diagnostic workup and management options. CASE PRESENTATION We report the case of a 12-year-old healthy male presenting with idiopathic short stature. He developed an itchy skin rash over the chest and abdomen, 15 min after administration of the first dose of rhGH, leading us to review allergic and non-allergic skin reactions to rhGH. In our patient, an immediate skin reaction after administration of rhGH prompted a concern about a type I hypersensitivity reaction (HS) and the discontinuation of rhGH. However, after a dermatologic evaluation and observed administration of rhGH without subsequent rash, the initial eruption was likely an exacerbation of his underlying atopic dermatitis and a type I HS was felt to be unlikely. The rhGH was resumed and he has been on rhGH for the past 1 year with no recurrence of rash and with improvement in growth velocity. CONCLUSIONS Though rare, allergic and non-allergic skin reactions are known to occur with rhGH. It is important to know if the allergic reaction was due to the growth hormone molecule or one of the preservatives. It is also important to consider a non-allergic reaction due to flare up of underlying skin disorders as in our patient.
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Affiliation(s)
- Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | - Vikash Oza
- The Ronald O. Perelman Department of Dermatology, Division of Pediatric Dermatology, New York University School of Medicine, New York, NY, USA
| | - Renee Potashner
- Ruth and Bruce Rappaport School of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Patricia Zamora
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | - Manish Raisingani
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | - Bina Shah
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
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22
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Matsumoto Y, Yamada H, Funazaki S, Suzuki D, Kakei M, Hara K. Effect of Liraglutide on Type B Insulin Resistance Syndrome and Insulin Allergy in Type 2 Diabetes: A Case Report. Diabetes Ther 2017; 8:1191-1194. [PMID: 28836180 PMCID: PMC5630548 DOI: 10.1007/s13300-017-0291-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION The appearance of anti-insulin antibodies or an allergy to insulin occasionally causes clinical problems with glycemic control in insulin users. METHODS In the present report, we describe a therapeutic approach that was employed for a man with type 2 diabetes who had insulin allergy, anti-insulin antibodies, and anti-insulin receptor antibodies that developed during his insulin treatment. RESULTS We started the patient on liraglutide, a glucagon-like peptide-1 receptor agonist, and attained glycemic control without incurring any side effects. Two years after liraglutide induction, his blood glucose was being maintained at a healthy level by liraglutide monotherapy. CONCLUSION Liraglutide may be a therapeutic option for patients with insulin allergy, anti-insulin antibodies, and type B insulin resistance syndrome, as it represents an alternative strategy to insulin.
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Affiliation(s)
- Yuko Matsumoto
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hodaka Yamada
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Shunsuke Funazaki
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Daisuke Suzuki
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Masafumi Kakei
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Kazuo Hara
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
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23
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Paula P, Oliveira J, Sousa D, Alves B, Carvalho A, Franco O, Vasconcelos I. Insulin-like plant proteins as potential innovative drugs to treat diabetes—The Moringa oleifera case study. N Biotechnol 2017; 39:99-109. [DOI: 10.1016/j.nbt.2016.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 06/21/2016] [Accepted: 10/07/2016] [Indexed: 12/25/2022]
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24
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Bavbek S, Lee MJ. Subcutaneous Injectable Drugs Hypersensitivity and Desensitization: Insulin and Monoclonal Antibodies. Immunol Allergy Clin North Am 2017; 37:761-771. [PMID: 28965639 DOI: 10.1016/j.iac.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Injectable drugs, including monoclonal antibodies, are becoming crucial components in the management of chronic diseases. The most common side effects are local reactions at the site of administration. With the increased and prolonged use of these medications, we are seeing increased reports of hypersensitivity reactions. The aim of this article is to discuss the signs and symptoms of these reactions as well as management, which may involve desensitization for 3 commonly encountered injectable drugs: tumor necrosis factor-α inhibitors (etanercept and adalimumab), insulin, and omalizumab.
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Affiliation(s)
- Sevim Bavbek
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara University School of Medicine, Mamak Street, Ankara 06100, Turkey.
| | - Min Jung Lee
- Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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25
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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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26
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Insulin allergy and the approach to a patient with insulin allergy. JOURNAL OF CONTEMPORARY MEDICINE 2016. [DOI: 10.16899/gopctd.283329] [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] Open
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27
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Engwerda EEC, Tack CJ, de Galan BE. A comparison of the pharmacodynamic profiles of jet-injected regular human insulin versus conventionally administered insulin aspart in healthy volunteers. Diabetes Res Clin Pract 2016; 121:86-90. [PMID: 27662042 DOI: 10.1016/j.diabres.2016.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 08/17/2016] [Accepted: 09/01/2016] [Indexed: 10/21/2022]
Abstract
AIMS Rapid-acting insulin analogues are generally preferred over regular human insulin because of their more immediate onset of action and shorter time-action profile. However, these analogues may not always be tolerated by or universally available for people with insulin-requiring diabetes. Jet injection has been demonstrated to facilitate faster insulin absorption. We determined whether administration of regular human insulin by jet injection achieves the same pharmacological properties as that of a rapid-acting insulin analogue. METHODS Twenty healthy volunteers received regular human insulin (0.2units/kg) by jet injection. Glucose 20% was infused intravenously to maintain euglycaemia over six hours. The glucose infusion rates (GIR) were determined to compare pharmacological profiles. These profiles were compared with data from two other studies in which a similar dose of insulin aspart was administered by conventional pen. RESULTS Regular human insulin by jet injection had a faster onset of glucose-lowering effect compared to aspart by conventional pen (T-GIR50%, 30.8±2.9 versus 43.1±3.2min, P<0.01). There were no differences in time to maximal GIR (106.1±11.9 versus 95.8±9.2min, P=0.50), maximal GIR (8.6±0.7 versus 7.7±0.7mg/kg/min, P=0.0.33), total glucose-lowering effect (101.0±9.8 versus 87.6±7.0g, P=0.28), and time until 50% of glucose disposal (144.8±5.6 versus 151.3±5.1min, P=0.39). CONCLUSIONS Jet-injected regular human insulin had a pharmacological profile that was essentially not dissimilar from that of aspart insulin administered by conventional pen, and can therefore be used as an alternative for conventionally administered rapid-acting insulin analogues.
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Affiliation(s)
- E E C Engwerda
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - C J Tack
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B E de Galan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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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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Abstract
Objective: A case of insulin allergy to insulin aspart, insulin aspart protamine/insulin aspart 70/30, insulin lispro, and insulin lispro protamine/insulin lispro 75/25 in a patient with type 2 diabetes mellitus is reported. Case Summary: A 76-year-old Caucasian male weighing 81 kg presented with complaints of burning, lumps, and a rash where his insulin aspart protamine/insulin aspart 70/30 was injected 2 months after initiation. Because poor injection technique can mimic insulin allergy, the patient was counseled again on proper injection technique. The patient presented 2 weeks later with the same complaints. Insulin aspart protamine/insulin aspart 70/30 was discontinued and insulin lispro protamine/insulin lispro 75/25 was initiated. The patient presented 3 months later with a localized reaction. Insulin lispro protamine/insulin lispro 75/25 was discontinued and insulin U100 glargine and insulin lispro were initiated. One week later, the patient still had complaints of a localized reaction and was referred to an allergist for testing. Skin prick tests revealed insulin allergy to insulin aspart and insulin lispro but not to insulin U100 glargine or insulin glulisine. The patient’s regimen was changed to insulin U100 glargine and insulin glulisine, and he has not experienced any reaction since. Discussion: Allergic reactions to human insulin preparations are rare and may present as a localized reaction or a generalized reaction. Different types of allergic reactions to human insulin have been reported, including type I, type III, and type IV hypersensitivity reactions. If insulin allergy is suspected, the following steps should be taken to confirm such allergy: evaluation of injection technique, switching to a different insulin preparation, and referral to an allergist for allergy testing if necessary. Conclusion: A patient with type 2 diabetes mellitus experienced a type I hypersensitivity reaction to insulin aspart, insulin aspart protamine/insulin aspart 70/30, insulin lispro, and insulin lispro protamine/insulin lispro 75/25.
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30
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Hirai H, Ogata E, Kikuchi N, Kohno T, Machii N, Hasegawa K, Watanabe T, Satoh H. The effects of liraglutide on both hypereosinophilic insulin allergy and the characteristics of anti-insulin antibodies in type 2 diabetes mellitus: a case report. J Med Case Rep 2016; 10:202. [PMID: 27456688 PMCID: PMC4960667 DOI: 10.1186/s13256-016-0994-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/06/2016] [Indexed: 12/27/2022] Open
Abstract
Background Liraglutide is one of the glucagon-like peptide-1 analogs; there are only a few reports of liraglutide being used for the treatment of insulin allergy. Furthermore, anti-insulin immunoglobulin G antibodies are occasionally detected in patients with diabetes. Hence, we report a case in which switching to liraglutide therapy ameliorated both the symptoms of insulin allergy with hypereosinophilia and the characteristics of insulin antibodies in a patient with type 2 diabetes mellitus. Case presentation We present the case of a 70-year-old Japanese man with type 2 diabetes who developed insulin allergy with hypereosinophilia. Anti-insulin antibodies, high glycated hemoglobin levels (approximately 12 %), and high serum insulin levels were detected. Because a change in his insulin treatment was inefficient, treatment with liraglutide to protect residual insulin secretion was started, resulting in improvements in his insulin allergy, serum glycated hemoglobin, insulin, and eosinophil levels. Scatchard plots revealed decreased binding capacity and increased affinity constant for high affinity sites of anti-insulin antibodies. Conclusions Liraglutide might be useful for treating insulin allergy and anti-insulin antibodies in patients with type 2 diabetes.
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Affiliation(s)
- Hiroyuki Hirai
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Emi Ogata
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Nobuyuki Kikuchi
- Department of Dermatology, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Teruyuki Kohno
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Noritaka Machii
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Koji Hasegawa
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Tsuyoshi Watanabe
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Hiroaki Satoh
- Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, 960-1295, Japan.
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Immunogenicity of Biotherapeutics: Causes and Association with Posttranslational Modifications. J Immunol Res 2016; 2016:1298473. [PMID: 27437405 PMCID: PMC4942633 DOI: 10.1155/2016/1298473] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/09/2016] [Accepted: 06/12/2016] [Indexed: 12/21/2022] Open
Abstract
Today, potential immunogenicity can be better evaluated during the drug development process, and we have rational approaches to manage the clinical consequences of immunogenicity. The focus of the scientific community should be on developing sensitive diagnostics that can predict immunogenicity-mediated adverse events in the small fraction of subjects that develop clinically relevant anti-drug antibodies. Here, we discuss the causes of immunogenicity which could be product-related (inherent property of the product or might be picked up during the manufacturing process), patient-related (genetic profile or eating habits), or linked to the route of administration. We describe various posttranslational modifications (PTMs) and how they may influence immunogenicity. Over the last three decades, we have significantly improved our understanding about the types of PTMs of biotherapeutic proteins and their association with immunogenicity. It is also now clear that all PTMs do not lead to clinical immunogenicity. We also discuss the mechanisms of immunogenicity (which include T cell-dependent and T cell-independent responses) and immunological tolerance. We further elaborate on the management of immunogenicity in preclinical and clinical setting and the unique challenges raised by biosimilars, which may have different immunogenic potential from their parent biotherapeutics.
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32
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Jefferis R. Posttranslational Modifications and the Immunogenicity of Biotherapeutics. J Immunol Res 2016; 2016:5358272. [PMID: 27191002 PMCID: PMC4848426 DOI: 10.1155/2016/5358272] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/20/2016] [Indexed: 12/23/2022] Open
Abstract
Whilst the amino acid sequence of a protein is determined by its gene sequence, the final structure and function are determined by posttranslational modifications (PTMs), including quality control (QC) in the endoplasmic reticulum (ER) and during passage through the Golgi apparatus. These processes are species and cell specific and challenge the biopharmaceutical industry when developing a production platform for the generation of recombinant biologic therapeutics. Proteins and glycoproteins are also subject to chemical modifications (CMs) both in vivo and in vitro. The individual is naturally tolerant to molecular forms of self-molecules but nonself variants can provoke an immune response with the generation of anti-drug antibodies (ADA); aggregated forms can exhibit enhanced immunogenicity and QC procedures are developed to avoid or remove them. Monoclonal antibody therapeutics (mAbs) are a special case because their purpose is to bind the target, with the formation of immune complexes (ICs), a particular form of aggregate. Such ICs may be removed by phagocytic cells that have antigen presenting capacity. These considerations may frustrate the possibility of ameliorating the immunogenicity of mAbs by rigorous exclusion of aggregates from drug product. Alternate strategies for inducing immunosuppression or tolerance are discussed.
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Affiliation(s)
- Roy Jefferis
- Institute of Immunology & Immunotherapy, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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33
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Kim GJ, Kim SB, Jo SI, Shin JK, Kwon HS, Jeong H, Son JW, Lee SS, Kim SR, Kim BK, Yoo SJ. Two Cases of Allergy to Insulin in Gestational Diabetes. Endocrinol Metab (Seoul) 2015; 30:402-7. [PMID: 26435137 PMCID: PMC4595367 DOI: 10.3803/enm.2015.30.3.402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/15/2014] [Accepted: 12/30/2014] [Indexed: 11/24/2022] Open
Abstract
Allergic reaction to insulin is uncommon since the introduction of human recombinant insulin preparations and is more rare in pregnant than non-pregnant females due to altered immune reaction during pregnancy. Herein, we report two cases of allergic reaction to insulin in gestational diabetes that were successfully managed. One case was a 33-year-old female using isophane-neutral protamine Hagedorn human insulin and insulin lispro. She experienced dyspnea, cough, urticaria and itching sensation at the sites of insulin injection immediately after insulin administration. We discontinued insulin therapy and started oral hypoglycemic agents with metformin and glibenclamide. The other case was a 32-year-old female using insulin lispro and insulin detemer. She experienced pruritus and burning sensation and multiple nodules at the sites of insulin injection. We changed the insulin from insulin lispro to insulin aspart. Assessments including immunoglobulin E (IgE), IgG, eosinophil, insulin antibody level and skin biopsy were performed. In the two cases, the symptoms were resolved after changing the insulin to oral agents or other insulin preparations. We report two cases of allergic reaction to human insulin in gestational diabetes due to its rarity.
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Affiliation(s)
- Gi Jun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Shin Bum Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Seong Il Jo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Jin Kyeong Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Hee Sun Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Heekyung Jeong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Jang Won Son
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Seong Su Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Sung Rae Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Byung Kee Kim
- Department of Clinical Pathology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Soon Jib Yoo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea.
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Belhekar MN, Pai S, Tayade P, Dalwadi P, Munshi R, Varthakavi P. A case of hypersensitivity to soluble and isophane insulins but not to insulin glargine. Indian J Pharmacol 2015; 47:227-9. [PMID: 25878390 PMCID: PMC4386139 DOI: 10.4103/0253-7613.153438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 01/18/2015] [Accepted: 02/11/2015] [Indexed: 11/04/2022] Open
Abstract
Insulin is an important agent for the treatment of diabetes mellitus (DM). Allergic reactions to insulin therapy, although rare, have been evident since animal insulin became available for the treatment of DM in 1922. Hypersensitivity to insulin has considerably been reduced with the introduction of human insulin produced by recombinant deoxyribonucleic acid technology. Here, we present a case of Type 2 DM who demonstrated immediate (Type 1) hypersensitivity reaction on the sites of subcutaneous injection of soluble and isophane insulin but insulin glargine was tolerated well and provided good glycemic control.
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Affiliation(s)
- Mahesh N Belhekar
- Department of Clinical Pharmacology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Sarayu Pai
- Department of Clinical Pharmacology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Parimal Tayade
- Department of Endocrinology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Pradip Dalwadi
- Department of Endocrinology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Renuka Munshi
- Department of Clinical Pharmacology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Prema Varthakavi
- Department of Endocrinology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
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35
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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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Petrovski G, Zivkovic M, Milenkovic T, Ahmeti I, Bitovska I. Successful desensitization in patient with type 2 diabetes with an insulin allergy using insulin pump and glargine. Acta Diabetol 2014; 51:1073-5. [PMID: 24811944 DOI: 10.1007/s00592-014-0591-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
Affiliation(s)
- G Petrovski
- Medical Faculty, University Clinic of Endocrinology, Diabetes and Metabolic Disorders, Vodnjanska 17, 1000, Skopje, Macedonia,
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Successful management of insulin allergy and autoimmune polyendocrine syndrome type 4 with desensitization therapy and glucocorticoid treatment: a case report and review of the literature. Case Reports Immunol 2014; 2014:394754. [PMID: 25548690 PMCID: PMC4274913 DOI: 10.1155/2014/394754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/30/2014] [Indexed: 12/25/2022] Open
Abstract
Introduction. Insulin allergy is a rare complication of insulin therapy, especially in type 1 diabetes mellitus (T1DM). Key manifestations are hypersensitivity-related symptoms and poor metabolic control. T1DM, as well as insulin allergy, may develop in the context of autoimmune polyendocrine syndrome (APS), further complicating management. Case Report. A 17-year-old male patient, diagnosed with T1DM, was treated with various insulin therapy schemes over several months, which resulted in recurrent anaphylactoid reactions and poor glycemic control, after which he was referred to our Endocrinology and Immunology Department. A prick test was carried out for all commercially available insulin presentations and another insulin scheme was designed but proved unsuccessful. A desensitization protocol was started with Glargine alongside administration of Prednisone, which successfully induced tolerance. Observation of skin lesions typical of vitiligo prompted laboratory workup for other autoimmune disorders, which returned positive for autoimmune gastritis/pernicious anemia. These findings are compatible with APS type 4. Discussion. To our knowledge, this is the first documented case of insulin allergy in type 4 APS, as well as this particular combination in APS. Etiopathogenic components shared by insulin allergy and APS beg for further research in immunogenetics to further comprehend pathophysiologic aspects of these diseases.
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39
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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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40
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Abstract
Children with multiple drug allergies are likely to require treatment with one or more of the drugs to which they may have had a reaction, when there is no alternate effective drug available. Detailed review of their history and/or use of appropriate diagnostic studies will help determine the potential safety of readministering the desired drug as well as the method for its readministration, most likely in the form of a drug challenge or desensitization. A practical approach to the diagnosis and treatment of children with multiple drug allergies is described in this review.
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Affiliation(s)
- Anahita Falakshahi Dioun
- Children's Hospital Boston, Division of Immunology, Harvard Medical School, Boston, MA 02115, USA.
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41
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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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42
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Hess R, Odle B. Insulin Therapy in Home Health. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2012. [DOI: 10.1177/1084822312458106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetes mellitus, whether type 1 or type 2, offers special challenges to home health care providers. Treatment of diabetes can become increasing complex. While insulin remains the cornerstone of treatment in patients with type 1 diabetes (T1DM), the utilization of insulin to safely control blood glucose is also necessary for many patients with type 2 diabetes (T2DM). Many different insulin products are available, with each product possessing different characteristics and adverse effect potential. Balancing glycemic control with patient safety is paramount. The individualization of insulin therapy can be challenging for both patients and health care professionals. Regular evaluation of blood glucose monitoring is vital for patient assessment. This article provides a review of insulin for providers caring for patients in the home health care setting.
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Affiliation(s)
- Rick Hess
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Brian Odle
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
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Abstract
BACKGROUND Insulin allergy is a not uncommon condition even though human insulin and insulin analogues are widely used. However, the development of insulin allergy after bone marrow transplantation has not been reported. CASE REPORT A 44-year-old Japanese woman had aplastic anaemia and secondary haemochromatosis. She was diagnosed with having diabetes at age 32 years and had been treated with human insulin. At age 34 years, bone marrow transplantation was performed. One year later, a rash and urticaria appeared immediately after insulin injections. Intracutaneous tests were positive for both human insulins and analogues, whereas the test for protamine was negative. Furthermore, an IgE-radioallergosorbent test against insulin was positive. Thus, we diagnosed the patient with having an IgE-mediated type I allergy against insulin. Insulin therapy with insulin aspart, which showed the least skin reaction, was continued and the insulin allergy disappeared in 7 years. CONCLUSIONS This is the first description of insulin allergy after bone marrow transplantation. Our case underscores the effects of bone marrow cells on IgE-mediated type I allergy for insulin.
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Affiliation(s)
- N Yoshida
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
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44
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Kawanami D, Ito T, Watanabe Y, Kinoshita J, Sakamoto M, Isaka T, Utsunomiya K. Successful control of a case of severe insulin allergy with liraglutide. J Diabetes Investig 2012; 4:94-6. [PMID: 24843637 PMCID: PMC4019294 DOI: 10.1111/j.2040-1124.2012.00239.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 07/04/2012] [Accepted: 07/04/2012] [Indexed: 11/29/2022] Open
Abstract
A 72‐year‐old woman presented with repeated hypoglycemic and hyperglycemic episodes because of an insulin allergy. On admission, she was diagnosed with type B insulin resistance syndrome. She was also found to have anti‐insulin antibodies. After steroid therapy, glycemic control improved dramatically accompanied by the disappearance of the insulin allergy. We then introduced liraglutide, which successfully stabilized her glycemic episodes without allergic reactions. Liraglutide might be useful to treat patients with severe insulin allergy.
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Affiliation(s)
- Daiji Kawanami
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Tomoko Ito
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Yui Watanabe
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Jun Kinoshita
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Masaya Sakamoto
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Tsuyoshi Isaka
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Kazunori Utsunomiya
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
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