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Momin ZK, Chambliss JM. Chronic spontaneous urticaria preceded by localized insulin reactions: case report. SAGE Open Med Case Rep 2024; 12:2050313X241248383. [PMID: 38655126 PMCID: PMC11036908 DOI: 10.1177/2050313x241248383] [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: 08/14/2023] [Accepted: 04/02/2024] [Indexed: 04/26/2024] Open
Abstract
Chronic spontaneous urticaria presents with wheals and/or angioedema for >6 weeks without any specific triggers. The incidence of chronic spontaneous urticaria is increased in patients with comorbid autoimmune conditions. Here, we present a case of chronic spontaneous urticaria in a 9-year-old with type 1 diabetes and autoimmune thyroid disease who first presented with insulin pump site reactions concerning an insulin-related allergy. The patient was successfully treated with antihistamines and later immunosuppression with resumption of insulin pump therapy and remission of chronic spontaneous urticaria symptoms 18 months after onset.
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Affiliation(s)
- Zoha K. Momin
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffrey M. Chambliss
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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2
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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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3
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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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Bevilacqua A, Obua A, Fonarov I, Casadesus D. Acute episode of erythrodermic psoriasis following self-administration of expired insulin glargine. BMJ Case Rep 2023; 16:e255472. [PMID: 37336622 PMCID: PMC10314417 DOI: 10.1136/bcr-2023-255472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Affiliation(s)
| | - Andre Obua
- Pathology and Laboratory Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Ilya Fonarov
- Hospital Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Damian Casadesus
- Hospital Medicine, Jackson Memorial Hospital, Miami, Florida, USA
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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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Huang J, Yeung AM, Kerr D, Gentile S, Heinemann L, Al-Sofiani ME, Joseph JI, Seley JJ, Klonoff DC. Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks. Endocr Pract 2023:S1530-891X(23)00386-5. [PMID: 37098370 DOI: 10.1016/j.eprac.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To review the current status of practical knowledge related to insulin-associated lipohypertrophy (LH) - an accumulation of fatty subcutaneous nodules commonly caused by repeated injections and/or infusions of insulin into the same site. METHODS Review of published literature with additional contributions from leading multidisciplinary experts with the emphasis on clinical aspects including pathophysiology, clinical and economic consequences, diagnosis, prevention and treatment. RESULTS LH is the most common dermatologic complication of insulin therapy. Risk factors for the development of lipohypertrophy include repeated delivery of large amounts of insulin into the same location over time, repeated injection trauma to the skin and subcutaneous tissue, and multiple injections using the same needle. Subcutaneous insulin injection in skin areas with lipohypertrophy is associated with reduced pain; however, this problem can interfere with insulin absorption, thereby increasing the likelihood of glucose variability, hypo- and hyperglycemia when a site is changed. Modern visualization technology of the subcutaneous space with ultrasound can demonstrate lipohypertrophy early in the course of its development. CONCLUSIONS The physiological and psychological consequences of developing insulin lipohypertrophy can be prevented and treated with education focusing on insulin injection techniques.
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Affiliation(s)
- Jingtong Huang
- Diabetes Technology Society, Burlingame, California, USA.
| | - Andrea M Yeung
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, California, USA
| | - Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy; NefroCenter Research Network, Torre del Greco, Naples, Italy
| | | | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jeffrey I Joseph
- Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, California, USA; Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
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7
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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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8
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Adamusiak AM, Ramanathan K, Moe T, Bellin MD, Kandaswamy R. Effective treatment of diabetes, improved quality of life and accelerated cognitive development after pancreas transplantation in a child with type 1 diabetes and allergy to manufactured insulin preparations. Pediatr Transplant 2023; 27:e14447. [PMID: 36451294 DOI: 10.1111/petr.14447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Insulin hypersensitivity reactions are rare but serious and significantly affect the treatment of diabetes in children. METHODS A 13-year-old girl with type 1 diabetes, hypoglycemic unawareness, and treatment refractory allergy to available insulin preparations underwent a solitary pancreas transplant. Before the pancreas transplantation, she was receiving a continuous subcutaneous infusion of rapid-acting insulin with an increasing need for antihistamines and steroids, negatively impacting her cognitive and social development. Her diabetes was poorly controlled, and her quality of life was progressively worsening. RESULTS Following the transplant, she recovered well from surgery and achieved euglycemia without needing exogenous insulin. She had two biopsy proven episodes of acute cellular rejection, successfully treated. Her cognitive development also accelerated. Notable improvement was noted both in her personal quality of life and her family's overall well-being. CONCLUSIONS This is the youngest pancreas transplant recipient with over 1-year graft survival reported in the literature. Pancreas transplant alone in a teenager without indications for kidney transplantation could be considered a last resort treatment for diabetes when continuing insulin therapy presents a high level of morbidity. A pancreas transplant is a feasible treatment modality for patients with refractory insulin allergy.
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Affiliation(s)
- Anna Maria Adamusiak
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.,Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karthik Ramanathan
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.,Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Tracy Moe
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Melena D Bellin
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.,Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Raja Kandaswamy
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.,Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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9
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Nagase T, Iwaya K, Zako T, Kikuchi M, Katsura Y. [Insulin-derived amyloidosis (insulin ball) and skin-related complications of insulin therapy]. Nihon Yakurigaku Zasshi 2023; 158:173-177. [PMID: 36858501 DOI: 10.1254/fpj.22109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Skin-related complications of insulin therapy have long been a problem as a factor interfering with insulin therapy. Among the traditional skin-related complications, lipoatrophy and insulin allergy have decreased markedly with the development of insulin preparations, but lipohypertrophy is still common in insulin-treated patients. Recently, there have been more reports of a skin-related complication called insulin-derived amyloidosis or insulin ball. Insulin-derived amyloidosis is a condition in which injected insulin becomes amyloid protein and is deposited at the injection site. Insulin-derived amyloidosis causes poor glycemic control and increased insulin dose requirements, which are caused by decreased insulin absorption. Lipohypertrophy also decreases insulin absorption, but insulin-derived amyloidosis causes a more significant decrease in insulin absorption and has a greater clinical impact. Therefore, it is important to make a differential diagnosis between insulin-derived amyloidosis and lipohypertrophy, but sometimes it is difficult to distinguish the two and imaging studies are required. The diagnosis of insulin-derived amyloidosis is often difficult in the general practice, and its pathogenesis and prevalence have not been fully clarified. Recently, it has been reported that insulin-derived amyloidosis can be toxic, suggesting an association with minocycline use. The treatment of insulin-derived amyloidosis and lipohypertrophy is to avoid the site of amyloidosis or lipohypertrophy and inject insulin, but the dose of insulin injection should be reduced. Prevention of both insulin-derived amyloidosis and lipohypertrophy is important, and for this purpose, observations of the insulin injection site and instruction on appropriate insulin injection techniques are necessary, and multidisciplinary cooperation is extremely important.
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Affiliation(s)
- Terumasa Nagase
- Noritake Clinic.,Department of Metabolism and Endocrinology, Tokyo Medical University Ibaraki Medical Center
| | - Keiichi Iwaya
- Department of Pathology, SASAKI Institute, Kyoundo Hospital
| | - Tamotsu Zako
- Department of Chemistry and Biology, Graduate School of Science and Engineering, Ehime University
| | - Minoru Kikuchi
- Faculty of Health Sciences, Department of Radiological Sciences, Japan Healthcare University
| | - Yoshiya Katsura
- Department of Metabolism and Endocrinology, Tokyo Medical University Ibaraki Medical Center
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10
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Abstract
PURPOSE OF REVIEW The purpose of this literature review was to review the latest advancements with biologics in rapid drug desensitization. Our methodology was to highlight both desensitization to biologics themselves and the use of biologics in desensitization to both biologic and nonbiologic drugs. RECENT FINDINGS Biologics are a vast category of drugs that include monoclonal antibodies, nanobodies, modern vaccinations, and even hormones. Desensitization to biologics can be safely performed through standardized procedure. Biomarkers are used both in vitro and in vivo to help identify and classify hypersensitivity reactions. Hypersensitivity reactions to the mRNA vaccinations against SARS-CoV-2 present their own unique challenges to management. There are specific excipients in monoclonal antibodies that are thought to be responsible for many of their hypersensitivity reactions. Certain biologics can even be used to assist in desensitization to other drugs. Rapid drug desensitization is a standardized procedure that may be able to help many patients who have experienced hypersensitivity reactions to biologics and would best be treated with them to continue to receive them. Biologic drugs have opened a new era in medicine for the prevention and treatment of infectious diseases, cancer, and inflammatory diseases. Hypersensitivity reactions to biologics are quite common. This literature review presents the latest advancements in our understanding of hypersensitivity reactions to biologics, how rapid drug desensitization can be used to continue therapy despite history of hypersensitivity, and how biologics themselves can be used to aid in desensitization itself.
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Affiliation(s)
- Barbara C Yang
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Room 5002-B, Boston, MA, 02115, USA.
- Ribon Therapeutics, 35 Cambridgepark Drive Suite 300, Cambridge, MA, 02140, USA.
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Room 5002-B, Boston, MA, 02115, USA
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11
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Ito Y, Sun R, Yagimuma H, Taki K, Mizoguchi A, Kobayashi T, Sugiyama M, Onoue T, Tsunekawa T, Takagi H, Hagiwara D, Iwama S, Suga H, Konishi H, Kiyama H, Arima H, Banno R. Protein Tyrosine Phosphatase 1B Deficiency Improves Glucose Homeostasis in Type 1 Diabetes Treated With Leptin. Diabetes 2022; 71:1902-1914. [PMID: 35748319 PMCID: PMC9862406 DOI: 10.2337/db21-0953] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 06/19/2022] [Indexed: 02/05/2023]
Abstract
Leptin, a hormone secreted by adipocytes, exhibits therapeutic potential for the treatment of type 1 diabetes (T1D). Protein tyrosine phosphatase 1B (PTP1B) is a key enzyme that negatively regulates leptin receptor signaling. Here, the role of PTP1B in the treatment of T1D was investigated using PTP1B-deficient (knockout [KO]) mice and a PTP1B inhibitor. T1D wild-type (WT) mice induced by streptozotocin showed marked hyperglycemia compared with non-T1D WT mice. KO mice displayed significantly improved glucose metabolism equivalent to non-T1D WT mice, whereas peripheral or central administration of leptin partially improved glucose metabolism in T1D WT mice. Peripheral combination therapy of leptin and a PTP1B inhibitor in T1D WT mice improved glucose metabolism to the same level as non-T1D WT mice. Leptin was shown to act on the arcuate nucleus in the hypothalamus to suppress gluconeogenesis in liver and enhance glucose uptake in both brown adipose tissue and soleus muscle through the sympathetic nervous system. These effects were enhanced by PTP1B deficiency. Thus, treatment of T1D with leptin, PTP1B deficiency, or a PTP1B inhibitor was shown to enhance leptin activity in the hypothalamus to improve glucose metabolism. These findings suggest a potential alternative therapy for T1D.
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Affiliation(s)
- Yoshihiro Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Runan Sun
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Yagimuma
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keigo Taki
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Mizoguchi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Sugiyama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Onoue
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taku Tsunekawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takagi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Konishi
- Department of Functional Anatomy and Neuroscience, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kiyama
- Department of Functional Anatomy and Neuroscience, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Nagoya, Japan
- Corresponding author: Ryoichi Banno,
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12
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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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13
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Pradhan R, Patorno E, Tesfaye H, Schneeweiss S, Yin H, Franklin J, Pawar A, Santella C, Yu OHY, Renoux C, Azoulay L. Glucagon-Like Peptide 1 Receptor Agonists and Risk of Anaphylactic Reaction Among Patients With Type 2 Diabetes: A Multisite Population-Based Cohort Study. Am J Epidemiol 2022; 191:1352-1367. [PMID: 35136902 PMCID: PMC9989345 DOI: 10.1093/aje/kwac021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 01/13/2022] [Accepted: 01/26/2022] [Indexed: 01/28/2023] Open
Abstract
Case reports and a pharmacovigilance analysis have linked glucagon-like peptide 1 receptor agonists (GLP-1 RAs) with anaphylactic reactions, but real-world evidence for this possible association is lacking. Using databases from the United Kingdom (Clinical Practice Research Datalink) and the United States (Medicare, Optum (Optum, Inc., Eden Prairie, Minnesota), and IBM MarketScan (IBM, Armonk, New York)), we employed a new-user, active comparator study design wherein initiators of GLP-1 RAs were compared with 2 different active comparator groups (initiators of dipeptidyl peptidase 4 (DPP-4) inhibitors and initiators of sodium-glucose cotransporter 2 (SGLT-2) inhibitors) between 2007 and 2019. Propensity score fine stratification weighted Cox proportional hazards models were fitted to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for an anaphylactic reaction. Database-specific HRs were pooled using random-effects models. Compared with the use of DPP-4 inhibitors (n = 1,641,520), use of GLP-1 RAs (n = 324,098) generated a modest increase in the HR for anaphylactic reaction, with a wide 95% CI (36.9 per 100,000 person-years vs. 32.1 per 100,000 person-years, respectively; HR = 1.15, 95% CI: 0.94, 1.42). Compared with SGLT-2 inhibitors (n = 366,067), GLP-1 RAs (n = 259,929) were associated with a 38% increased risk of anaphylactic reaction (40.7 per 100,000 person-years vs. 29.4 per 100,000 person-years, respectively; HR = 1.38, 95% CI: 1.02, 1.87). In this large, multisite population-based cohort study, GLP-1 RAs were associated with a modestly increased risk of anaphylactic reaction when compared with DPP-4 inhibitors and SGLT-2 inhibitors.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Laurent Azoulay
- Correspondence to Dr. Laurent Azoulay, Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, 3755 Côte Sainte-Catherine, Suite H425.1, Montreal, QC H3T 1E2, Canada (e-mail: )
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14
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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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15
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Takahashi K, Anno T, Takenouchi H, Iwamoto H, Horiya M, Kimura Y, Kawasaki F, Kaku K, Tomoda K, Kaneto H. Serious diabetic ketoacidosis induced by insulin allergy and anti-insulin antibody in a subject with type 2 diabetes mellitus. J Diabetes Investig 2022; 13:1788-1792. [PMID: 35587395 PMCID: PMC9533051 DOI: 10.1111/jdi.13838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes mellitus, and is characterized by hyperglycemia, metabolic acidosis and increased total ketone body concentrations. The main mechanism of DKA is a lack of insulin in the body. It has been reported that some immunological response is associated with insulin therapy. Herein, we report a case of serious DKA, which was induced by insulin allergy and anti‐insulin antibody. This case clearly shows that DKA can be induced by insulin allergy and anti‐insulin antibodies in individuals with type 2 diabetes treated with insulin. Furthermore, we should know that as the required insulin dose might be very high under severe insulin resistance and serious DKA in such cases, we should increase the insulin dose appropriately while monitoring pH, base excess and other factors.
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Affiliation(s)
- Kaio Takahashi
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Haruka Takenouchi
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Hideyuki Iwamoto
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Megumi Horiya
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, 701-0192, Japan
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16
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Mohapatra L, Mangaraj S. Erythema annulare centrifugum associated with insulin therapy: a case report. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Liza Mohapatra
- SOA IMS and SUM Hospital, Kalinga Nagar Bhubaneswar 751003 India
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17
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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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18
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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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19
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Qureshi K, Naeem N, Tariq J, Chaudhry MS, Pasha F. New-Onset Insulin Allergy After COVID-19 Infection in an Insulin-Dependent Type-2 Diabetic Patient: A Rare Complication. Cureus 2021; 13:e17879. [PMID: 34660078 PMCID: PMC8502509 DOI: 10.7759/cureus.17879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/05/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is an infectious respiratory disease caused by the novel coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Initially, it was reported in December 2019 and became a global pandemic in March 2020, with many presentations and after-effects. We report the case of a 68-year-old female patient who presented to the emergency room with the chief complaint of a skin rash and itching all over her body, developing within a few minutes of insulin injection. The patient had tested positive for COVID-19 almost eight days ago and was self-quarantined. She was a known diabetic for the past 28 years. Her blood glucose levels were maintained within the normal range by a combination regimen of oral anti-diabetic drugs and subcutaneous humulin 70/30 (70% neutral protamine Hagedorn (NPH) insulin and 30% regular human insulin) injections. After careful examination and thorough history taking, a newly acquired insulin allergy was diagnosed in the patient, attributed to her disrupted immune system due to the recent COVID-19 infection.
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Affiliation(s)
- Khadija Qureshi
- Internal Medicine, Bucks County Kidney Specialists, Langhorne, USA
| | - Nauman Naeem
- Internal Medicine, Mayo Hospital Lahore, Lahore, PAK
| | - Javera Tariq
- Hematology, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Maida S Chaudhry
- Internal Medicine, DHR Health Institute For Research And Development, Edinburg, USA
| | - Fajar Pasha
- Internal Medicine, Holy Family Hospital, Rawalpindi, PAK
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20
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Pfiester E, Braune K, Thieffry A, Ballhausen H, Gajewska KA, O'Donnell S. Costs and underuse of insulin and diabetes supplies: Findings from the 2020 T1International cross-sectional web-based survey. Diabetes Res Clin Pract 2021; 179:108996. [PMID: 34363862 DOI: 10.1016/j.diabres.2021.108996] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 11/27/2022]
Abstract
AIMS To investigate self-reported out-of-pocket expenses (OoPE) associated with insulin and diabetes supplies for people living with type 1 diabetes (T1D) worldwide. METHODS A web-based, cross-sectional survey was conducted from August to December 2020. The analysis included comparisons between responses from countries with no, partial, and full healthcare coverage. RESULTS 1,066 participants from 64 countries took part in the study. ~25% of respondents reported having underused insulin at least once within the last year due to perceived cost. A significant correlation was observed between OoPEs and reported household income for respondents with partial healthcare coverage. 63.2% of participants reported disruption of insulin supplies and 25.3% reported an increase of prices related to the COVID-19 pandemic. CONCLUSIONS This study confirms previous reports of ~25% of people in the United States with T1D using less insulin and/or fewer supplies at least once in the last year due to cost, a trend associated with the extent of healthcare coverage. Similar trends were observed in some middle/low income countries. Moreover, patients reported an increase in insulin prices and disruption of supplies during the COVID-19 pandemic. This study highlights the importance of self-reported OoPEs and its association with underuse/rationing of insulin.
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Affiliation(s)
| | - Katarina Braune
- T1International, Cheltenham, UK; Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Axel Thieffry
- Center for Biosustainability, Technical University of Denmark, Copenhagen, Germany
| | - Hanne Ballhausen
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; #dedoc° Diabetes Online Community, Dedoc Labs GmbH, Berlin, Germany
| | - Katarzyna Anna Gajewska
- School of Public Health, University College Cork, Cork, Ireland; Diabetes Ireland, Dublin, Ireland
| | - Shane O'Donnell
- School of Sociology, University College Dublin, Belfield, Ireland.
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21
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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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22
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Wu Y, Lou X. Multifocal lipoatrophy secondary to insulin injection in a patient with type 2 diabetes, hepatitis B virus infection, and liver cirrhosis. J Int Med Res 2021; 49:300060521990237. [PMID: 33682487 PMCID: PMC7944535 DOI: 10.1177/0300060521990237] [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] [Indexed: 12/25/2022] Open
Abstract
Lipoatrophy secondary to insulin injection is a rare complication of insulin use. Localized lipoatrophy is recognized by a loss of subcutaneous fat caused by insulin injection. We report the case of a 69-year-old non-obese female patient with type 2 diabetes mellitus, decompensated liver cirrhosis, and hepatitis B virus (HBV) infection who developed multifocal lipoatrophy during the administration of human insulin and an insulin analog.
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Affiliation(s)
- Yuedan Wu
- Department of Endocrinology, Dongyang People's Hospital, Jinhua City, Zhejiang, China
| | - Xiaojia Lou
- Department of Endocrinology, Dongyang People's Hospital, Jinhua City, Zhejiang, China
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23
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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24
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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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25
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Clarke B, Loudovaris T, Radford T, Drogemuller C, Coates PT, Torpy D. Ambulatory intravenous insulin and islet cell transplantation to treat severe type III insulin hypersensitivity in a patient with type 1 diabetes mellitus. Clin Case Rep 2020; 8:2759-2762. [PMID: 33363817 PMCID: PMC7752599 DOI: 10.1002/ccr3.3200] [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: 06/09/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022] Open
Abstract
Allogenic pancreatic islet cell transplantation is an appropriate treatment option to consider in the management of refractory cases of severe hypersensitivity to insulin in patients with type 1 diabetes mellitus.
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Affiliation(s)
- Brigette Clarke
- Department of Endocrinology and MetabolismRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of Health and Medical SciencesSchool of MedicineThe University of AdelaideAdelaideSAAustralia
| | | | - Toni Radford
- Central Northern Adelaide Renal and Transplantation ServiceRoyal Adelaide HospitalAdelaideSAAustralia
| | - Chris Drogemuller
- Faculty of Health and Medical SciencesSchool of MedicineThe University of AdelaideAdelaideSAAustralia
- Central Northern Adelaide Renal and Transplantation ServiceRoyal Adelaide HospitalAdelaideSAAustralia
| | - Patrick Toby Coates
- Faculty of Health and Medical SciencesSchool of MedicineThe University of AdelaideAdelaideSAAustralia
- Central Northern Adelaide Renal and Transplantation ServiceRoyal Adelaide HospitalAdelaideSAAustralia
| | - David Torpy
- Department of Endocrinology and MetabolismRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of Health and Medical SciencesSchool of MedicineThe University of AdelaideAdelaideSAAustralia
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26
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Lijesh KU, Gupta RD, SenthilRaja M, Kapoor N, Paul TV, Thomas N. Exogenous recombinant human insulin-induced severe hypersensitivity reaction precipitating hyperglycemic crisis: A clinical conundrum. J Family Med Prim Care 2020; 9:4470-4472. [PMID: 33110889 PMCID: PMC7586586 DOI: 10.4103/jfmpc.jfmpc_148_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/13/2020] [Accepted: 06/10/2020] [Indexed: 11/04/2022] Open
Abstract
Hypersensitivity reactions against exogenous insulin are a rare clinical entity after the advent of recombinant human insulin; however, there are still case reports wherein patients develop hypersensitivity reactions against insulin. We present the case of a type 1 diabetes mellitus patient who developed type 1 hypersensitivity reaction against subcutaneous insulin. He had recurrent episodes of diabetic ketoacidosis after developing hypersensitivity reactions against insulin, requiring multiple hospital admissions. When he presented to us, he was on both insulin infusion and subcutaneous insulin, requiring a daily insulin dose of about 800 units and having severe insulin hypersensitivity reactions and hyperglycemia. He had multiple subcutaneous erythematous nodules at the insulin injection sites, however, had no evidence of systemic allergy. Investigations revealed eosinophilic leukocytosis, and high IgE levels and skin biopsy showing evidence of insulin hypersensitivity. He was desensitized to insulin according to Heinzerling et al. insulin desensitization protocol and subsequently with immunomodulation therapy using steroids (pulse methylprednisolone) and mycophenolate mofetil as well as by installation of insulin pump.
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Affiliation(s)
- K U Lijesh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC) Vellore, Tamil Nadu, India
| | - Riddhi Das Gupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC) Vellore, Tamil Nadu, India
| | - M SenthilRaja
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC) Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC) Vellore, Tamil Nadu, India
| | - Thomas V Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC) Vellore, Tamil Nadu, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC) Vellore, Tamil Nadu, India
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27
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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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28
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Fast simultaneous quantification of gabapentin and cetirizine in cell lysates by means of HPLC-MS/MS. J Pharm Biomed Anal 2020; 184:113172. [DOI: 10.1016/j.jpba.2020.113172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/07/2020] [Accepted: 02/12/2020] [Indexed: 11/18/2022]
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29
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Harvey JN, Cronin M, Arkwright P. Insulin hypersensitivity in type 1 diabetes: investigation and treatment with immunodepletion. PRACTICAL DIABETES 2020. [DOI: 10.1002/pdi.2265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- John N Harvey
- Professor and Consultant Physician, Betsi Cadwaladr University Health Board, Gladstone Centre, Maelor Hospital; Wrexham UK
| | - Michael Cronin
- Consultant Paediatrician, Betsi Cadwaladr University Health Board, Department of Paediatrics; Ysbyty Gwynedd, Bangor UK
| | - Peter Arkwright
- Consultant Paediatric Immunologist, Royal Manchester Children's Hospital; Manchester UK
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30
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Ayaz F, Arikoglu T, Demirhan A, Kuyucu S. A novel whole blood based method for lymphocyte transformation test in drug allergies. J Immunol Methods 2020; 479:112745. [PMID: 31958448 DOI: 10.1016/j.jim.2020.112745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/14/2020] [Indexed: 12/27/2022]
Abstract
Drug allergies pose a great deal of danger for the patients. It hinders effective treatment procedures in hospitalized patients. Moreover, it complicates the symptoms due to the allergic reactions of the immune system. Allergic reactions may arise against any medication including antibiotics and chemotherapeutics. Therefore, it is crucial to assess the sensitization pattern of the patients to culprit drug(s) before retreatment with the same or similar drug, or in order to confirm/exclude a suspected drug hypersensitivity reaction. In vivo and in vitro tests are performed in the evaluation of patients. Current methods of in vitro drug allergy evaluations rely on time consuming and expensive methods. Ficoll separation of peripheral blood mononuclear cells, their activation with stimulants in the presence of the drug of interest, CD69 or CD25 or BrdU or radioactive thymidine analysis of the cells after a couple of days of incubation is an excessively elaborate work and also uneconomical. Moreover, it requires a great deal of expertise to interpret the results. Here, we are reporting a new whole blood based lymphocyte transformation test method that does not require ficoll separation, CD69, CD25, BrdU and radioactive thymidine analysis. Thanks to the color change in the whole blood itself one can easily determine the allergic reaction to a certain drug. This new method is less time consuming, more economical and easy to apply.
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Affiliation(s)
- Furkan Ayaz
- Department of Biotechnology, Faculty of Arts and Science, Mersin University, Mersin 33343, Turkey.
| | - Tugba Arikoglu
- Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin 33343, Turkey
| | - Ali Demirhan
- Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin 33343, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin 33343, Turkey.
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31
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Nguyen AD, Luong CQ, Chu HC, Nguyen VKD, Nguyen CV, Nguyen TA, Nguyen QH, Mai TD, Nguyen DV, Nguyen BQ, Tran TH, Dao PV, Nguyen DT, Nguyen NN, Do SN. Successful management of severe diabetic ketoacidosis in a patient with type 2 diabetes with insulin allergy: a case report. BMC Endocr Disord 2019; 19:121. [PMID: 31711488 PMCID: PMC6849168 DOI: 10.1186/s12902-019-0451-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion. CASE PRESENTATION A 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 min of injection and lasting over 24 h. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 μmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 h, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites. CONCLUSIONS In this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.
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Affiliation(s)
- Anh Dat Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Chinh Quoc Luong
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Hieu Chi Chu
- Allerology and Clinical Immunology Center, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Van Khoa Dieu Nguyen
- Emergency Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Allergy and Clinical Immunology, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Chi Van Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Quan Huu Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Ton Duy Mai
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Dinh Van Nguyen
- Allerology and Clinical Immunology Center, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Bay Quang Nguyen
- Emergency Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Allergy and Clinical Immunology, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Thong Huu Tran
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Phuong Viet Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Dat Tuan Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Nguyet Nhu Nguyen
- Allerology and Clinical Immunology Center, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Son Ngoc Do
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
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Chawla R, Makkar BM, Aggarwal S, Bajaj S, Das AK, Ghosh S, Gupta A, Gupta S, Jaggi S, Jana J, Keswadev J, Kalra S, Keswani P, Kumar V, Maheshwari A, Moses A, Nawal CL, Panda J, Panikar V, Ramchandani GD, Rao PV, Saboo B, Sahay R, Setty KR, Viswanathan V, Aravind SR, Banarjee S, Bhansali A, Chandalia HB, Das S, Gupta OP, Joshi S, Kumar A, Kumar KM, Madhu SV, Mittal A, Mohan V, Munichhoodappa C, Ramachandran A, Sahay BK, Sai J, Seshiah V, Zargar AH. RSSDI consensus recommendations on insulin therapy in the management of diabetes. Int J Diabetes Dev Ctries 2019. [DOI: 10.1007/s13410-019-00783-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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33
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Tan ALM, Langley SR, Tan CF, Chai JF, Khoo CM, Leow MKS, Khoo EYH, Moreno-Moral A, Pravenec M, Rotival M, Sadananthan SA, Velan SS, Venkataraman K, Chong YS, Lee YS, Sim X, Stunkel W, Liu MH, Tai ES, Petretto E. Ethnicity-Specific Skeletal Muscle Transcriptional Signatures and Their Relevance to Insulin Resistance in Singapore. J Clin Endocrinol Metab 2019; 104:465-486. [PMID: 30137523 DOI: 10.1210/jc.2018-00309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 08/14/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Insulin resistance (IR) and obesity differ among ethnic groups in Singapore, with the Malays more obese yet less IR than Asian-Indians. However, the molecular basis underlying these differences is not clear. OBJECTIVE As the skeletal muscle (SM) is metabolically relevant to IR, we investigated molecular pathways in SM that are associated with ethnic differences in IR, obesity, and related traits. DESIGN, SETTING, AND MAIN OUTCOME MEASURES We integrated transcriptomic, genomic, and phenotypic analyses in 156 healthy subjects representing three major ethnicities in the Singapore Adult Metabolism Study. PATIENTS This study contains Chinese (n = 63), Malay (n = 51), and Asian-Indian (n = 42) men, aged 21 to 40 years, without systemic diseases. RESULTS We found remarkable diversity in the SM transcriptome among the three ethnicities, with >8000 differentially expressed genes (40% of all genes expressed in SM). Comparison with blood transcriptome from a separate Singaporean cohort showed that >95% of SM expression differences among ethnicities were unique to SM. We identified a network of 46 genes that were specifically downregulated in Malays, suggesting dysregulation of components of cellular respiration in SM of Malay individuals. We also report 28 differentially expressed gene clusters, four of which were also enriched for genes that were found in genome-wide association studies of metabolic traits and disease and correlated with variation in IR, obesity, and related traits. CONCLUSION We identified extensive gene-expression changes in SM among the three Singaporean ethnicities and report specific genes and molecular pathways that might underpin and explain the differences in IR among these ethnic groups.
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Affiliation(s)
- Amelia Li Min Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore
| | - Sarah R Langley
- Duke-National University of Singapore Medical School, Singapore
- National Heart Centre Singapore, Singapore
| | - Chee Fan Tan
- Nanyang Institute of Technology in Health and Medicine, Nanyang Technological University, Singapore
- School of Biological Sciences, Nanyang Technological University, Singapore
| | - Jin Fang Chai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Chin Meng Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore
| | - Melvin Khee-Shing Leow
- Duke-National University of Singapore Medical School, Singapore
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Eric Yin Hao Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore
| | | | - Michal Pravenec
- Institute Of Physiology, Czech Academy Of Sciences, Prague, Czech Republic
| | - Maxime Rotival
- Unit of Human Evolutionary Genetics, Institut Pasteur, Paris, France
| | - Suresh Anand Sadananthan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore
| | - S Sendhil Velan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore
- Singapore Bioimaging Consortium, Agency for Science, Technology and Research (A*STAR), Singapore
| | - Kavita Venkataraman
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Yap Seng Chong
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yung Seng Lee
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Paediatrics Endocrinology, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore
| | - Xueling Sim
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Walter Stunkel
- Experimental Biotherapeutics Centre, Agency for Science, Technology and Research (A*STAR), Singapore
| | - Mei Hui Liu
- Department of Chemistry, Food Science & Technology Programme, National University of Singapore, Singapore
| | - E Shyong Tai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore
| | - Enrico Petretto
- Duke-National University of Singapore Medical School, Singapore
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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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Oray NC, Bayram B, Altintas E, Sivrikaya S, Savran Y. Severe allergic reaction to human insulin in the patient with diabetic ketoacidosis. Turk J Emerg Med 2018; 18:40-41. [PMID: 29942883 PMCID: PMC6009812 DOI: 10.1016/j.tjem.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/17/2017] [Accepted: 07/26/2017] [Indexed: 11/25/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is an acute and major life-threatening complication of diabetes mellitus. Fluid resuscitation, insulin therapy, and electrolyte replacement are essential for DKA treatment. Rarely, life threatening allergic reactions might develop in a patient treated with insulin. If anaphylaxis develops after insulin, the DKA treatment options are restricted. A limited number of case reports have been reported in patients with severe anaphylactic reactions to human insulin who were then treated with synthetic insulin analogues. We present a case of a 45-year-old male patient with allergic reactions to human insulin. The patient was successfully treated with insulin aspart and hemodialysis.
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Affiliation(s)
- Nese Colak Oray
- Dokuz Eylul University, Faculty of Medicine, Department of Emergency Medicine, Balcova, 35340, Izmir, Turkey
| | - Basak Bayram
- Dokuz Eylul University, Faculty of Medicine, Department of Emergency Medicine, Balcova, 35340, Izmir, Turkey
| | - Emel Altintas
- Adiyaman University, Training and Research Hospital, Department of Emergency Medicine, Adiyaman, Turkey
| | - Semra Sivrikaya
- Artvin State Hospital, Department of Emergency Medicine, Artvin, Turkey
| | - Yusuf Savran
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Balcova, 35340, Izmir, Turkey
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Mishra S, Connors L, Tugwell B. Role of omalizumab in insulin hypersensitivity: a case report and review of the literature. Diabet Med 2018; 35:663-666. [PMID: 29381818 DOI: 10.1111/dme.13591] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- S Mishra
- Department of Medicine, Division of Clinical Immunology and Allergy, Western University, London, Ontario, Canada
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - L Connors
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Medicine, Division of General Internal Medicine (Clinical Immunology & Allergy), Dalhousie University, Halifax, Nova Scotia, Canada
| | - B Tugwell
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Medicine, Division of Endocrinology and Metabolism, Dalhousie University, Halifax, Nova Scotia, Canada
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Bhatia A, Tawade S, Mastim M, Kitabi EN, Gopalakrishnan M, Shah M, Yeshamaina S, Gobburu J, Sahib M, Thakur D, Prasanna Kumar KM. Comparative evaluation of pharmacokinetics and pharmacodynamics of insulin glargine (Glaritus ®) and Lantus ® in healthy subjects: a double-blind, randomized clamp study. Acta Diabetol 2018; 55:461-468. [PMID: 29453671 DOI: 10.1007/s00592-018-1113-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/01/2018] [Indexed: 10/18/2022]
Abstract
AIMS The objective of the study was to compare the pharmacokinetic (PK) and pharmacodynamic (PD) properties of an insulin glargine formulation, Glaritus® (test) with the innovator's formulation Lantus® (reference) using the euglycemic clamp technique in a single-dose, double-blind, randomized, two sequences, four-period replicate crossover study in healthy volunteers (n = 40). METHODS Subjects received subcutaneous administration of the insulin glargine (0.4 IU/kg) formulation at two occasions for test and reference and a 20% glucose solution was infused at variable rate to maintain euglycemia for 24 h. RESULTS Both PK [area under the plasma concentration time curve (AUC0-24 h) and maximum insulin concentration (Cmax)] and PD endpoints [area under glucose infusion rate time curve (AUCGIR0-24) and maximum glucose infusion rate (GIRmax)] demonstrated bioequivalence of Glaritus to Lantus with the 90% confidence interval of geometric mean ratio of test to reference entirely contained within 0.80-1.25. Both formulations showed equivalent geometric least-square mean LSM value (0.08 nmol/L) for Cmax. The geometric LSM AUC0-24 h value for Glaritus® (1.09 h nmol/L) was comparable to Lantus (1.05 h nmol/L). Median Tmax values were also identical (12 h for both), and median t1/2 values were also equal (18 h for both). For GIRTmax, the difference between the means for the two was not statistically significant. No AEs related to study formulations were reported, and both products were well tolerated. CONCLUSIONS The test product (Glaritus) was found to be bioequivalent to the reference product (Lantus). CLINICAL TRIAL REGISTRATION NUMBER CTRI/2015/06/005890; http://www.ctri.nic.in/ .
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Affiliation(s)
- Ashima Bhatia
- Wockhardt, Global Clinical Development, BKC, Mumbai, India
| | | | | | - Eliford Ngaimisi Kitabi
- School of Pharmacy, Center for Translational Medicine, University of Maryland, 20 N. Pine Street, Baltimore, MD, 21201, USA
| | - Mathangi Gopalakrishnan
- School of Pharmacy, Center for Translational Medicine, University of Maryland, 20 N. Pine Street, Baltimore, MD, 21201, USA.
| | - Manish Shah
- Wockhardt, Global Clinical Development, BKC, Mumbai, India
| | | | - Joga Gobburu
- School of Pharmacy, Center for Translational Medicine, University of Maryland, 20 N. Pine Street, Baltimore, MD, 21201, USA
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Özlek B, Özlek E, Çelik O, Çil C, Doğan V, Biteker M. Allergic myocardial infarction following recombinant human insulin. Heart Lung 2018; 47:360-362. [PMID: 29709318 DOI: 10.1016/j.hrtlng.2018.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/30/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Allergic myocardial infarction is a rare clinical entity. OBJECTIVES Although a few number of case reports with severe anaphylactic reactions to recombinant human insulin have been reported, allergic myocardial infarction, known as Kounis Syndrome, has not been reported before. METHODS Herein, we report a 57-year-old woman with myocardial infarction, referred for urticarial rash, chest pain, and palpitations developed after the first subcutaneous dose of recombinant human insulin. RESULTS The patient treated with antihistamines and steroids and discharged from hospital in a good condition. CONCLUSIONS Physicians should be aware of allergic myocardial infarction. The diagnosis of Kounis Syndrome should be entertained when allergic symptoms, electrocardiographic changes, and high cardiac enzymes accompany acute-onset chest pain. All patients admitted to the emergency department with chest pain and ST elevation on electrocardiography should be asked about allergic insults.
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Affiliation(s)
- Bülent Özlek
- Muğla University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey.
| | - Eda Özlek
- Muğla University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey
| | - Oğuzhan Çelik
- Muğla University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey
| | - Cem Çil
- Muğla University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey
| | - Volkan Doğan
- Muğla University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey
| | - Murat Biteker
- Muğla University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey
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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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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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Rare drug allergies: Review on prevalence and test procedures. Allergol Select 2017; 1:160-168. [PMID: 30402614 PMCID: PMC6040010 DOI: 10.5414/alx01578e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 02/14/2013] [Indexed: 12/13/2022] Open
Abstract
This paper gives a review on rare hypersensitivity reactions (including allergies) to drugs. Pathogenesis, allergy tests and possible therapeutic options are discussed by presenting examples out of the following group of drugs: antiinfectious (i.e. chinolones, telaprevir), oncological (i.e. platin-based cytostatics), immunologic (i.e. cetuximab, omalizumab), others (i.e. glucocorticosteroids). Usually there is no standardized allergologcial work-up procedure. Testing must therefore take into consideration previous experiences from other authors and on general recommendations.
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Abstract
Diabetes mellitus is a widespread endocrine disease with severe impact on health systems worldwide. Increased serum glucose causes damage to a wide range of cell types, including endothelial cells, neurons, and renal cells, but also keratinocytes and fibroblasts. Skin disorders can be found in about one third of all people with diabetes and frequently occur before the diagnosis, thus playing an important role in the initial recognition of underlying disease. Noninfectious as well as infectious diseases have been described as dermatologic manifestations of diabetes mellitus. Moreover, diabetic neuropathy and angiopathy may also affect the skin. Pruritus, necrobiosis lipoidica, scleredema adultorum of Buschke, and granuloma annulare are examples of frequent noninfectious skin diseases. Bacterial and fungal skin infections are more frequent in people with diabetes. Diabetic neuropathy and angiopathy are responsible for diabetic foot syndrome and diabetic dermopathy. Furthermore, antidiabetic therapies may provoke dermatologic adverse events. Treatment with insulin may evoke local reactions like lipohypertrophy, lipoatrophy and both instant and delayed type allergy. Erythema multiforme, leukocytoclastic vasculitis, drug eruptions, and photosensitivity have been described as adverse reactions to oral antidiabetics. The identification of lesions may be crucial for the first diagnosis and for proper therapy of diabetes.
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Mastrorilli C, Rizzuti L, Cangelosi AM, Iovane B, Chiari G, Caffarelli C. Long-acting insulin allergy in a diabetic child. Int J Immunopathol Pharmacol 2017; 30:174-177. [PMID: 28368217 PMCID: PMC5806792 DOI: 10.1177/0394632017700431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Insulin allergy has been uncommon since the introduction of human recombinant insulin preparations; the prevalence is 2.4%. Insulin injection could elicit immediate reactions, which are usually induced by an IgE-mediated mechanism, within the first hour after drug administration. In the present study, we describe the case of a child who experienced immediate urticaria after long-acting insulin injection. A 9-year-old girl affected by type I diabetes mellitus referred a history of three episodes of urticaria 30 min after insulin subcutaneous injection. During the first week of insulin therapy, she developed generalized immediate urticaria twice after long-acting insulin glargine first and then once after insulin degludec administration. Symptoms resolved within a few hours after treatment with oral antihistamine. She tolerated rapid insulin lispro. Her personal allergological history was negative. Skin prick tests with degludec, glargine and detemir were performed, showing negative results. Intradermal 1:100000-diluted tests were immediately positive for both degludec and glargine but not for detemir. In light of these findings, detemir was administered without any reaction. Our results show that detemir is tolerated by patients with clinical hypersensitivity reactions to degludec and glargine. Although reactions could be attributable to additives allergy, such as zinc or metacresol, this was excluded since all three preparations contain the same components. So, insulin itself acted as offending allergen. Detemir differs from degludec and glargine in a few aminoacids. Therefore, it is possible that the conformational rather than the linear epitope may be responsible for the reaction. This result suggests integrating intradermal tests in the diagnostic flowchart for insulin allergy. Insulin allergy should always be suspected in patients with immediate symptoms after drug injection. As allergologic work-up, prick by prick test and intradermal test to insulin preparations should be performed. In case of negative results of cutaneous tests, insulin analogs may be administered.
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Affiliation(s)
- Carla Mastrorilli
- 1 Clinica Pediatrica, Azienda Ospedaliero-Universitaria di Parma, Unit of Allergy and Immunology in Evolutive Age, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Laura Rizzuti
- 1 Clinica Pediatrica, Azienda Ospedaliero-Universitaria di Parma, Unit of Allergy and Immunology in Evolutive Age, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Antonina Marta Cangelosi
- 2 General and Emergency Pediatrics, Clinica Pediatrica, Unit of Pediatric Diabetology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Brunella Iovane
- 2 General and Emergency Pediatrics, Clinica Pediatrica, Unit of Pediatric Diabetology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giovanni Chiari
- 2 General and Emergency Pediatrics, Clinica Pediatrica, Unit of Pediatric Diabetology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Carlo Caffarelli
- 1 Clinica Pediatrica, Azienda Ospedaliero-Universitaria di Parma, Unit of Allergy and Immunology in Evolutive Age, Department of Medicine and Surgery, University of Parma, Parma, Italy
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A case of local delayed-type allergy to zinc-containing insulin as a cause of diabetic ketoacidosis in a patient with type 1 diabetes mellitus undergoing continuous subcutaneous insulin infusion. Diabetol Int 2016; 7:447-450. [DOI: 10.1007/s13340-016-0264-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/02/2016] [Indexed: 11/26/2022]
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Murphy LA, Zuendt GF, Nakamura RK, Gambardella P. Hypersensitivity reaction associated with subcutaneous glargine insulin therapy in a cat. JFMS Open Rep 2016; 2:2055116916668892. [PMID: 28491437 PMCID: PMC5362920 DOI: 10.1177/2055116916668892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/15/2022] Open
Abstract
CASE SUMMARY A 14-year-old, domestic shorthair cat was treated for transient diabetes mellitus for 3 months with glargine insulin, which was discontinued when the diabetes mellitus resolved. Approximately 36 months later the diabetes mellitus recurred and glargine insulin was restarted. Within 2-3 mins of the first injection the cat collapsed, developed profuse vomiting and diarrhea, as well as facial swelling and diffuse erythema. A hypersensitivity reaction was suspected and the cat was treated with antihistamines, aggressive fluid therapy and gastrointestinal support. The cat made a full recovery and was discharged 3 days later. Six months later the cat re-presented for relapse of its diabetes mellitus and an intradermal skin challenge with 1:20 diluted insulin was performed confirming a hypersensitivity to glargine. The cat continues to be well regulated on porcine zinc insulin without any hypersensitivity reactions noted. RELEVANCE AND NOVEL INFORMATION Hypersensitivity reactions to insulin administration are rarely described in human medicine. This is the first reported case of a hypersensitivity reaction secondary to glargine insulin in a cat. Clinicians should be aware of this potential complication, particularly in animals with a previous history of insulin administration and the potential to utilize intradermal testing with insulin.
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Affiliation(s)
- Lisa A Murphy
- Oradell Animal Hospital, Emergency Department, Paramus, NJ, USA
| | - Greg F Zuendt
- Oradell Animal Hospital, Emergency Department, Paramus, NJ, USA
| | - Reid K Nakamura
- Veterinary Specialty and Emergency Center, Emergency and Cardiology Departments, Thousand Oaks, CA, USA
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Fujishiro M, Izumida Y, Takemiya S, Kuwano Y, Takamoto I, Suzuki R, Yamauchi T, Ueki K, Kadowaki T. A case of insulin allergy successfully managed using multihexamer-forming insulin degludec combined with liraglutide. Diabet Med 2016; 33:e26-e29. [PMID: 26485621 DOI: 10.1111/dme.12998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Insulin allergy, one of insulin's adverse effects, is rare, especially in patients with Type 2 diabetes, but management is difficult and no effective strategy has yet been established. We experienced an insulin allergy case successfully managed with a novel combination of insulins. CASE REPORT A 38-year-old woman started insulin therapy when diabetes was diagnosed at age 19 years. Despite poorly controlled diabetes because of poor adherence, she hoped to conceive a child and continuous subcutaneous insulin infusion was introduced using insulin aspart at age 32 years. One month thereafter, she developed skin reactions at the subcutaneous insulin infusion catheter insertion site. The patient was then tested for all rapid-acting insulin formulations, all of which triggered local reactions. She decided to continue the continuous subcutaneous infusion of human regular insulin, accompanied by oral cetirizine hydrochloride and betamethasone valerate ointment. The patient was admitted to our hospital at age 38 years with high HbA1c levels. She was tested for all long-acting insulin analogues. All results, except for insulin degludec, were positive. She discontinued continuous subcutaneous insulin infusion and switched to insulin degludec combined with liraglutide. The allergic reactions had completely disappeared and her blood glucose was well controlled by the time of discharge. CONCLUSION Our patient was allergic to all insulin formulations except insulin degludec. Her allergic reactions completely disappeared after switching to insulin degludec. The crystallized structure of this insulin might mask its skin allergen antigenicity. Furthermore, her postprandial hyperglycaemia was successfully controlled with liraglutide. We propose multihexamer-forming ultra-long-acting insulin plus glucagon-like peptide-1 analogues as a therapeutic option for patients with insulin allergy.
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Affiliation(s)
- M Fujishiro
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan.
| | - Y Izumida
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - S Takemiya
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Y Kuwano
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - I Takamoto
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - R Suzuki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - T Yamauchi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - K Ueki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - T Kadowaki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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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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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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50
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Badik J, Chen J, Letvak K, So TY. Hypersensitivity Reaction to Insulin Glargine and Insulin Detemir in a Pediatric Patient: A Case Report. J Pediatr Pharmacol Ther 2016; 21:85-91. [PMID: 26997933 DOI: 10.5863/1551-6776-21.1.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Allergy to human insulin or its analogs is rare, but it is still a significant issue in current diabetes care. Allergic reactions can range from localized injection site reactions to generalized anaphylaxis, and they can be caused by excipients or the insulin molecules themselves. We presented a case of a 14-year-old male patient with generalized allergic reactions to insulin glargine and insulin detemir. The patient was successfully managed by being switched to a continuous subcutaneous insulin infusion with insulin aspart. Allergic reactions to insulin detemir and insulin glargine have both been well described, with insulin detemir allergy appearing to be more common. There are several potential mechanisms for insulin allergy, and immunologic characteristics vary among different insulin analogs. After confirming insulin allergy in practice, management involves treating symptoms and switching insulin preparations. This is the first documented case of allergies to both insulin glargine and insulin detemir in a pediatric patient. Exact mechanism of insulin allergy is unknown, and management strategies must be individualized for each patient.
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Affiliation(s)
- Jennifer Badik
- Department of Pediatric Endocrinology, Cone Health Pediatric Sub-Specialists of Greensboro, Greensboro, North Carolina
| | - Jimmy Chen
- Medical Student, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kira Letvak
- University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Tsz-Yin So
- Department of Pharmacy, Moses H. Cone Hospital, Greensboro, North Carolina
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