Primary systemic allergy to human insulin: recurrence of generalized urticaria after successful desensitization

Insulin Allergy to Detemir Followed by Rapid Onset of Diabetic Ketoacidosis: A Case Report and Literature Review

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.

The complexities of insulin allergy: a case and approach

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.

Role of omalizumab in insulin hypersensitivity: a case report and review of the literature

BACKGROUND

Insulin allergy is a rare yet severe side effect of exogenous insulin use. Management typically involves use of alternative antihyperglycaemic agents, symptom control with antihistamines, use of different insulin formulations, and induction of tolerance with incremental doses of insulin. This treatment regimen is not always successful, and the use of omalizumab, an anti-IgE monoclonal antibody, has been used to induce tolerance to insulin.

CASE REPORT

G.M. is a 62-year-old man with Type 2 diabetes mellitus. His condition was not optimized on oral agents, and insulin therapy was required. G.M. had anaphylaxis to insulin NPH, and subsequent skin-prick testing was positive to insulin aspart, insulin NPH, insulin glulisine, insulin detemir, regular insulin, insulin glargine 100 units/ml and insulin glargine 300 units/ml. He received incremental doses of several insulin formulations; however, he experienced diffuse urticaria preventing optimal glycaemic control. Three successful cases have been described in the literature of omalizumab inducing tolerance to exogenous insulin; therefore, G.M. was started on omalizumab. He subsequently tolerated treatment doses of insulin glulisine and insulin detemir with no allergic reactions and with improvement in glycaemic control.

CONCLUSION

To our knowledge, this is the first described case of allergy to insulin glargine 300 units/ml and reiterates the potential use of omalizumab in insulin allergy. Further research is warranted to determine if omalizumab should be considered standard of care in difficult-to-treat insulin hypersensitivity.

Cutaneous allergy to insulin: could statins and ACE inhibitors play a role? A case report

Insulin allergy is rare. Both statins and angiotensin converting enzyme (ACE) inhibitors may cause local urticarial skin reactions and have been implicated to precipitate local reactions to insulin. We describe a case of a localised urticarial allergic reaction related to insulin use in a patient co-prescribed an ACE inhibitor and statin.

Immunogenicity to biologics: mechanisms, prediction and reduction

Currently, there is a significant rise in the development and clinical use of a unique class of pharmaceuticals termed as Biopharmaceuticals or Biologics, in the management of a range of disease conditions with, remarkable therapeutic benefits. However, there is an equally growing concern regarding development of adverse effects like immunogenicity in the form of anti-drug antibodies (ADA) production and hypersensitivity. Immunogenicity to biologics represents a significant hurdle in the continuing therapy of patients in a number of disease settings. Efforts focussed on the identification of factors that contribute towards the onset of immunogenic response to biologics have led to reductions in the incidence of immunogenicity. An in-depth understanding of the cellular and molecular mechanism underpinning immunogenic responses will likely improve the safety profile of biologics. This review addresses the mechanistic basis of ADA generation to biologics, with emphasis on the role of antigen processing and presentation in this process. The article also addresses the potential contribution of complement system in augmenting or modulating this response. Identifying specific factors that influences processing and presentation of biologic-derived antigens in different genotype and disease background may offer additional options for intervention in the immunogenic process and consequently, the management of immunogenicity to biologics.

Clinical applications of drug desensitization in the Asia-Pacific region

Drug desensitization is the induction, within hours to days, of a temporary state of tolerance to a drug which the patient has developed a hypersensitivity reaction to. It may be used for IgE and non-IgE mediated allergic reactions, and certain non-allergic reactions. The indication for desensitization is where no alternative medications are available for the treatment of that condition, and where the benefits of desensitization outweigh the risks. Desensitization is a therapeutic modality for drug allergy (similar to allergen specific immunotherapy for allergic rhinitis and insect venom anaphylaxis). In contrast, the drug provocation test is a diagnostic modality used to confirm or refute the diagnosis of drug allergy. This review discusses the clinical applications of desensitization for the treatment of common infectious, metabolic and cardiovascular diseases, and oncological conditions in the Asia-Pacific region.

Allergic reactions to human insulin: a review of current knowledge and treatment options

Although the incidence of insulin allergy decreased after the introduction of recombinant human insulin preparations, it is still a major problem which may be life-threatening in some cases. In this article, we attempted to review current knowledge concerning allergic reactions to human insulin and discuss the available treatment options of insulin allergy.

Insulin allergy: clinical manifestations and management strategies

Insulin allergy in patients with diabetes mellitus on insulin treatment is a rare condition. It is suspected upon noticing immediate symptoms following insulin injections. The immediate vital implications for the patient call for prompt diagnosis and management of insulin allergy. We review current knowledge and procedures based on four diabetic patients who presented in our clinic. Insulin allergy was suspected as they showed immediate symptoms after insulin injection (urticaria, rash, angioedema, hypotension, dyspnea). A detailed allergologic work-up was performed and adequate therapy was initiated. In three of the four patients, a specific immunotherapy was started whereas in one patient a switch to oral antidiabetics was possible and consequently initiated. By standard prick testing and measurement of specific IgE antibodies, a type 1 IgE-mediated allergy was confirmed. After initiation of insulin immunotherapy, the symptoms completely resolved in two out three of patients and significantly improved in the third patient. The fourth patient was successfully switched to oral antidiabetics. Insulin allergy is a rare but severe condition that calls for immediate allergological work-up. It can be managed well in close cooperation between the diabetologist and the allergologist. Specific immunotherapy is efficient and should be considered.

Successful induction of tolerance to infliximab in patients with Crohn's disease and prior severe infusion reactions

AIM

To appraise the tolerance and efficacy of an induction of tolerance protocol to infliximab permitting the re-administration of the drug to patients with Crohn's disease having had infusion reactions requiring suspension of treatment.

METHODS

Fourteen patients were included in the induction of tolerance protocol. Each infusion of infliximab (5 mg/kg) was divided into 11 escalating 15 min increments over a 3-h time period. The induction of tolerance procedure was repeated for subsequent infusions.

RESULTS

Ten patients (71.4%) received all the three infusions for the induction treatment. Nine (64.3%) had a significant response and six (48.8%) still benefited from infliximab infusions. Seven patients (50%) achieved a complete remission, after a mean of 2.5 (two to three) infusions. Four patients (28.6%) had no response and the protocol was stopped. Three patients (21.4%) experienced mild immediate hypersensitivity reactions, which were controlled, two patients (14.2%) experienced severe immediate hypersensitivity reactions, leading to interruption of the treatment and one patient developed a delayed hypersensitivity reaction.

CONCLUSION

Our induction of tolerance protocol allows some patients who have experienced severe or repetitive infusion reactions to infliximab to be safely retreated with the drug in a hospitalized setting, with a clinical response achieved in a majority of these patients.

Solitary pancreas transplantation for life-threatening allergy to human insulin*

We report on a 30-year-old man, with type 1 diabetes mellitus, who developed generalized allergy to insulin consisting of several bouts of tremor, tachycardia, breathlessness and syncope. Strong positive reactions to protamine and metacresol were demonstrated by skin-prick testing. Symptoms persisted despite the use of antihistamine therapy, Actrapid HM Paraben and Monotard (insulin without protamine and metacresol) and immunosuppression (tacrolimus). He underwent a cadaver pancreas transplantation with portal-enteric drainage in June 2003. Following the antithymocyte globulin induction, immunosuppression consisted in tacrolimus and sirolimus without steroids. The patient subsequently reported a complete resolution of his symptoms and excellent glycaemic control. Thirteen months after transplantation, the patient developed oral ulcerations and severe leucopoenia initially attributed to sirolimus, which was subsequently stopped. A hyperglycaemic episode following corticosteroid therapy for acute rejection therapy required the reintroduction of insulin. Allergic manifestations reappeared promptly. Currently, 2 years after transplantation, the patient is euglycaemic without insulin (glycated haemoglobin 5.8%) and he is free of allergic reactions.

Insulin allergy; desensitization with crystalline zinc-insulin and steroid tapering

The insulin analogues, aspart and lispro, have been considered safe alternatives for patients with insulin allergy, because of their decreased immunogenicity. However, recent several reports showed that neither of them was completely free from allergic reactions. We also experienced a patient with insulin allergy not only to human regular insulin but also to both of the insulin analogues. Interestingly, the insulin analogues, which readily dissociate from polymer to monomer, induced the most severe allergic reaction among several types of human insulin reagents in the present case. Allergy to crystalline zinc-insulin, the three-dimensional structure of which results in delayed dissociation and absorption, was negative on intradermal tests. However, its large subcutaneous injection caused local allergic reaction. These results suggested that the allergic reaction might depend on the rapidity of insulin monomerization and absorption, and thus that the immunogenic residue of insulin is concealed when insulin is polymerized. Based on the intradermal tests, we speculated that the antigenic epitope might be B30-Thr in the present case. We also report here the modified method of insulin desensitization using crystalline zinc-insulin with prednisolone tapering. This might be a simple and useful treatment for insulin allergy.

IgE-mediated allergy and desensitization to factor IX in hemophilia B

BACKGROUND

We describe two patients with factor IX deficiency and high levels of inhibitors to factor IX who developed anaphylaxis to factor IX.

OBJECTIVE

The aim of this study was to develop a skin test, RAST, and desensitization protocol for factor IX allergy.

METHODS

The patients were evaluated by skin test and RAST to factor IX. They also underwent desensitization to factor IX.

RESULTS

Both patients had positive skin test and RAST reactions to factor IX. Control subjects had negative reactions. Both patients were successfully desensitized to factor IX by using two different desensitization protocols. The patients' skin test and RAST reactions to factor IX converted to negative after desensitization.

CONCLUSIONS

IgE-mediated reactions to factor IX do occur and may be diagnosed with the use of skin test and RAST. Patients with this type of reaction may be successfully desensitized to factor IX.