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DeClue CE, Phillips EJ, Prieto-Granada C, Bao S. Rituximab Therapy for Insulin Allergy in Type-1 Diabetes Mellitus. AACE Clin Case Rep 2024; 10:140-143. [PMID: 39100637 PMCID: PMC11294739 DOI: 10.1016/j.aace.2024.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/11/2024] [Accepted: 04/11/2024] [Indexed: 08/06/2024] Open
Abstract
Background/Objective Allergic reactions to insulin have decreased significantly since the introduction of human insulin preparation, but up to 2.4% of insulin-treated patients can still be affected. Rituximab is a monoclonal antibody against the surface antigen CD20 on B lymphocytes, and it is largely used to treat lymphoproliferative and rheumatological conditions. In a very few published case reports, rituximab has been used as an investigational drug to treat severe insulin allergy refractory to conventional therapy. Here, we present an unusual case of a 40-year-old woman with T1DM and severe insulin allergy that was successfully treated with rituximab. Case Report The patient was diagnosed with T1DM at age 37. Three years later, skin reactions developed at insulin administration sites. These consisted of pruritic and painful erythema and wheals that appeared within 1 to 4 h of insulin administration, followed by induration, subcutaneous nodules, and surrounding lipodystrophy that lasted several days with spontaneous resolution in 1 to 2 weeks. Extensive immunologic evaluation suggested the reaction was related to insulin allergy. Skin biopsy revealed sublobular panniculitis. After failed conventional treatment with antihistamines, glucocorticoid, and various insulins, rituximab infusion as an investigational approach was initiated. This was very successful, leading to prolonged remission of her insulin allergy. Discussion First-line management of insulin allergy should focus on second-generation antihistamines and switching insulin preparation. In refractory cases, systemic immunotherapy with rituximab can be a viable option. Conclusion Practitioners should be aware that in patients with insulin allergy who fail conventional treatment, immunotherapy with rituximab can be a viable option.
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Affiliation(s)
- Cory E. DeClue
- Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Shichun Bao
- Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
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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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Aranda CS, Aun MV, Souza CFMD, Pinto LLDC, Porras-Hurtado GL, Salgado OFS, Arantes RR, Martins AM, Solé D. Hypersensitivity reactions and enzyme replacement therapy: Outcomes and safety of rapid desensitization in 1,008 infusions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:870-873.e1. [PMID: 34742930 DOI: 10.1016/j.jaip.2021.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Carolina Sanchez Aranda
- Department of Pediatrics, Escola Paulista de Medicina-Federal University of São Paulo (EPM-UNIFESP), SP, Brazil and Reference Center on Inborn Errors of Metabolism (CREIM) of the Department of Pediatrics, EPM-UNIFESP.
| | - Marcelo Vivolo Aun
- Albert Einstein Israeli Faculty of Health Sciences, Brazil and Department of Internal Medicine, Faculty of Medicine, University of São Paulo, SP, Brazil
| | | | | | | | | | | | - Ana Maria Martins
- Department of Pediatrics, EPM-UNIFESP, SP, Brazil and CREIM, Department of Pediatricians, EPM-UNIFESP
| | - Dirceu Solé
- Department of Pediatrics, EPM-UNIFESP, SP, Brazil
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Guarneri AM, Hoffman RP. Non-glycemic Adverse Effects of Insulin. Curr Diabetes Rev 2022; 18:e012821190877. [PMID: 33511950 DOI: 10.2174/1573399817666210129104420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/22/2022]
Abstract
Insulin is primarily considered for its glycemic effects in patients with diabetes. There are, however, non-glycemic adverse effects of insulin that may significantly impact patient health and interfere with glycemic control. Insulinogenic edema primarily occurs with rapid improvement in glycemic control either in patients with newly discovered diabetes or in patients with poorly-controlled diabetes. Insulin-induced sympathetic activation, vasodilation, changes in vascular permeability, and most importantly, sodium retention play significant etiologic roles in the development of edema. Clinically, it is usually self-limited, but significant complications can develop. Allergic reactions to all insulin preparations and various compounds used in insulin formulations with a wide range of severity have been reported. Frequently, changing the type of insulin or delivery method is sufficient, but more advanced treatments such as insulin desensitization and anti-IgE antibody treatment may be needed. Lipohypertrophy and lipoatrophy frequently develop with the overuse of injection sites. Lipohypertrophy can affect tissue insulin absorption and glycemic control.
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Affiliation(s)
- Alissa M Guarneri
- Department of Pediatrics Division of Endocrinology and Diabetes UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, PA 15224, USA
| | - Robert P Hoffman
- Department of Pediatrics Division of Endocrinology Nationwide Children\'s Hospital The Ohio State University College of Medicine Columbus, OH 43205, USA
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Aberumand B, Jeimy S. The complexities of insulin allergy: a case and approach. Allergy Asthma Clin Immunol 2021; 17:79. [PMID: 34325725 PMCID: PMC8320219 DOI: 10.1186/s13223-021-00554-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Insulin hypersensitivity is rare, but challenging for individuals with diabetes. The prevalence of insulin allergy has decreased since the introduction of human recombinant insulin preparations. Hypersensitivity reactions range from injection site erythema and swelling, to anaphylaxis. While some reactions are to excipients (zinc, protamine, metacresol), many are to recombinant insulin itself. We present a case of type 1 hypersensitivity to various preparations of insulin in a patient with insulin-dependent type 2 diabetes mellitus (T2DM). Case presentation A 61-year-old woman with a 30-year history of insulin-dependent T2DM was referred for evaluation of reactions to insulin. She had two episodes over 5-months; both required Emergency Department visits and epinephrine administration. The first episode entailed a burning sensation of the extremities and nausea, immediately after injecting NovoRapid® insulin. The second event entailed a similar reaction but this time there was also angioedema of the upper airway with difficulty breathing and hypotension, immediately after injecting Levemir® and NovoRapid®, and taking metformin. There were no cofactors such as exercise, infectious illness, or NSAIDs use. Skin testing was performed with metformin, Lantus®, Humalog®, NovoRapid®, glulisine, insulin regular, NPH, Levemir® and the excipient protamine, as per published testing concentrations. Metacresol was not tested as its use was restricted by the hospital pharmacy. Insulin preparations with and without metacresol were included in testing however. A clinic staff served as a negative control. The patent had negative testing with protamine, but sensitization to all insulin preparations. Metformin skin testing and challenge along with latex IgE were negative. Subsequently, she underwent intentional weight loss of 70 lb, and was started on oral hypoglycemics with good effect. Conclusions Our case highlights the importance of diagnosing insulin allergy through a detailed history and focused testing. Therapeutic strategies include avoidance and insulin alternatives, alternate insulin preparations, or desensitization. In severe recurrent hypersensitivity reactions, Omalizumab or pancreatic transplantation have been effective.
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Affiliation(s)
- Babak Aberumand
- Division of Allergy and Immunology, Department of Medicine, University of Toronto, 30 Bond St. M5B 1W8, Toronto, ON, Canada.
| | - Samira Jeimy
- Division of Allergy and Immunology, Department of Medicine, Western University, London, ON, Canada
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Vultaggio A, Matucci A, Nencini F, Bormioli S, Vivarelli E, Maggi E. Mechanisms of Drug Desensitization: Not Only Mast Cells. Front Pharmacol 2020; 11:590991. [PMID: 33424601 PMCID: PMC7793680 DOI: 10.3389/fphar.2020.590991] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/25/2020] [Indexed: 12/30/2022] Open
Abstract
Drug desensitization (DD) allows transient clinical tolerance to the drug in reactive patients and it is frequently and successfully used in the management of both IgE and non IgE-mediated hypersensitivity reactions (HRs). The underlying mechanisms behind this process is not well understood. The desensitization procedure is associated with the inhibition of mast cells degranulation and cytokine production, that, is attributable, at least partially, to the abrogation of Ca2+ mobilization; in vitro findings and in vivo mouse models of rapid desensitization show that the organization and spatial distribution of actin is critical for Ca2+ mobilization. Some clinical observations may suggest the induction of a longer memory of tolerance by DD and they raise the suspicion that other cells and mechanisms are involved in DD. Some data are emerging about the modifications of immune responses during DD in patients with previous immediate HRs. In particular, an increase of regulatory cytokines, mainly represented by IL-10, has been shown, and more importantly, the appearance of IL-35 producing T regulatory cells has been described during DD. The release of controlled cellular mediators by mast cells over time and the development of the antigen-specific regulation of adaptive response allow to safely and successfully reach the target dose of a first line drug during DD.
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Affiliation(s)
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Nencini
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Susanna Bormioli
- Immunology and Cellular Therapy, Careggi University Hospital, Florence, Italy
| | | | - Enrico Maggi
- Translational Immunology Unit, Immunology Area, Pediatric Hospital Bambino Gesù, IRCCS, Rome, Italy
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Abstract
PURPOSE OF REVIEW The use of biologicals as therapeutic agents in oncology and other inflammatory diseases has dramatically increased during the last years. Due to their biological nature and inherent immunological activity, they are able to induce important adverse events, such as cytokine release reactions (rapid release of proinflammatory cytokines), serum sickness disease, and immediate or delayed hypersensitivity reactions, including anaphylaxis. The aim of the current article is to review the state of the art of anaphylaxis because of biological agents. RECENT FINDINGS Different phenotypes, and potential underlying endotypes, have been described in anaphylactic reactions to biologicals. There seems to be a spectrum from type 1 reactions (IgE or non-IgE-mediated) to cytokine release reactions, with some reactions falling in between both. Management should be directed according to such phenotypes. SUMMARY There is ongoing research to further define immediate adverse reactions to biologicals and to find relevant biomarkers to aid in their diagnosis. Such information will serve in defining their immediate and long term management.
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Shuster S, Borici-Mazi R, Awad S, Houlden RL. RAPID DESENSITIZATION WITH INTRAVENOUS INSULIN IN A PATIENT WITH DIABETIC KETOACIDOSIS AND INSULIN ALLERGY. AACE Clin Case Rep 2020; 6:e147-e150. [PMID: 32671215 PMCID: PMC7357611 DOI: 10.4158/accr-2019-0562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/25/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We report a case of insulin desensitization in a patient with known allergy to multiple insulin preparations who presented with diabetic ketoacidosis (DKA). METHODS Clinical and laboratory data, and desensitization protocols are presented. RESULTS A 65-year-old woman with type 2 diabetes and a documented insulin allergy presented with severe DKA. She was managed initially with intravenous (IV) fluids, sodium bicarbonate, and hemodialysis. An intradermal skin test was positive for 0.01 units/mL of human regular insulin. A rapid desensitization protocol for IV human regular insulin was initiated after pretreatment with methylprednisolone, ranitidine, montelukast, and cetirizine. An initial dilution of 1 unit of insulin in 100,000 mL of 0.9% sodium chloride was started at 5 mL/hour IV. The dilution was increased at 60-minute intervals to 1 unit/10,000 mL, 1 unit/1,000 mL, 1 unit/100 mL, 1 unit/10 mL, then 1 unit/1 mL. The dose was then increased from 1 to 7 units/hour (0.1 units/kg body weight/hour). The anion gap closed after 24 hours, and overlapping desensitization was started for subcutaneous (SC) human regular insulin starting with 0.00001 units with a gradual increase to 7 units before meals and 6 units at bedtime over 5 days. There were no anaphylactic reactions to IV or SC insulin. She was discharged with human regular insulin SC 4 times daily, oral montelukast, cetirizine, diphenhydramine as needed, and an epinephrine pen. No allergic reactions were reported at follow-up visits. CONCLUSION Rapid insulin desensitization is possible to allow treatment of DKA with human regular insulin IV in patients with known insulin allergy.
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10
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Calogiuri G, Nettis E, Mandurino-Mirizzi A, Di Leo E, Macchia L, Foti C, Vacca A, Kounis NG. Omalizumab for the Treatment of Persistent Drug Induced Urticaria Elicited by Thienopyridines: A Case Report. Antiinflamm Antiallergy Agents Med Chem 2019; 19:335-339. [PMID: 31113348 DOI: 10.2174/1871523018666190522105055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 11/22/2022]
Abstract
The anti-IgE Omalizumab may be helpful to treat clopidogrel hypersensitivity without stopping thienopyridine administration in patients requirining continuous antiplatellet therapy after coronary stent placement.
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Affiliation(s)
- Gianfranco Calogiuri
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | - Eustachio Nettis
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | | | - Elisabetta Di Leo
- Section of Allergy and Clinical Immunology, Unit of Internal Medicine-"F. Miulli" Hospital, Acquaviva Delle Fonti, Bari, Italy
| | - Luigi Macchia
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | - Caterina Foti
- Department of Biomedical Science and Human Oncology, Dermatological Clinic, University of Bari, 70124 Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Patras, Greece
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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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