1
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Fueermann F, Heller K, Pavel M, Herbst L, Grützmann R, Schiffer M. Pancreas transplantation as rescue therapy in a patient with type 1 diabetes and concurrent subcutaneous insulin resistance. Am J Transplant 2024:S1600-6135(24)00458-1. [PMID: 39094952 DOI: 10.1016/j.ajt.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
Patients with type 1 diabetes and concurrent subcutaneous insulin resistance present unique diagnostic and therapeutic challenges for clinicians. The standard therapeutic approach is the administration of intravenous insulin. Pancreatic transplantation should be considered at an appropriate time, particularly in the event of life-threatening ketoacidosis, hyperglycemia, hypoglycemia, catheter-associated thrombosis and infections. We present the case of a 24-year-old female patient with type 1 diabetes since early childhood and increasingly uncontrollable subcutaneous and intramuscular insulin resistance. Furthermore, we present the diagnostic pathway and therapeutic interventions performed, culminating in pancreatic transplantation as a curative approach. Immediate graft function resulted in optimal glycemic control.
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Affiliation(s)
- Florian Fueermann
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Ulmenweg 18, 91045 Erlangen, Germany.
| | - Katharina Heller
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Ulmenweg 18, 91045 Erlangen, Germany
| | - Marianne Pavel
- Department of Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Ulmenweg 18, 91045 Erlangen, Germany
| | - Larissa Herbst
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Ulmenweg 18, 91045 Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Krankenhausstr. 12, 91045 Erlangen, Germany
| | - Mario Schiffer
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Ulmenweg 18, 91045 Erlangen, Germany
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2
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Fourman LT, Tsai LL, Brown RJ, O'Rahilly S. Case 10-2024: A 46-Year-Old Woman with Hyperglycemia Refractory to Insulin Therapy. N Engl J Med 2024; 390:1219-1229. [PMID: 38598578 DOI: 10.1056/nejmcpc2312729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Lindsay T Fourman
- From the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Massachusetts General Hospital, and the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Harvard Medical School - both in Boston; the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health - both in Bethesda, MD (R.J.B.); and the Department of Clinical Biochemistry, University of Cambridge, Cambridge, United Kingdom (S.O.)
| | - Leo L Tsai
- From the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Massachusetts General Hospital, and the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Harvard Medical School - both in Boston; the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health - both in Bethesda, MD (R.J.B.); and the Department of Clinical Biochemistry, University of Cambridge, Cambridge, United Kingdom (S.O.)
| | - Rebecca J Brown
- From the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Massachusetts General Hospital, and the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Harvard Medical School - both in Boston; the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health - both in Bethesda, MD (R.J.B.); and the Department of Clinical Biochemistry, University of Cambridge, Cambridge, United Kingdom (S.O.)
| | - Stephen O'Rahilly
- From the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Massachusetts General Hospital, and the Departments of Medicine (L.T.F.) and Radiology (L.L.T.), Harvard Medical School - both in Boston; the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health - both in Bethesda, MD (R.J.B.); and the Department of Clinical Biochemistry, University of Cambridge, Cambridge, United Kingdom (S.O.)
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3
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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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4
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Asaka H, Karashima S, Chujo D, Kometani M, Usukura M, Yagi K, Aiga K, Yoneda T. In vivo relationship between bound and free insulin in patients with diabetes having anti-insulin antibodies. Diabetol Int 2023; 14:427-433. [PMID: 37781465 PMCID: PMC10533445 DOI: 10.1007/s13340-023-00641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/29/2023] [Indexed: 10/03/2023]
Abstract
Objective The Scatchard plot of anti-insulin antibodies is curvilinear, indicating heterogeneity in binding sites. However, the relationship between bound insulin (B) and free insulin (F) in patients with anti-insulin antibodies has not yet been elucidated. This study aimed to determine this relationship. Methods We studied two insulin-treated patients with diabetes who had high titers of anti-insulin antibodies. The B and F levels were measured using daily blood samples. Assuming that the law of mass action is applicable to the reactions between insulin and anti-insulin antibody forms, we plotted the bound-to-free ratio (B/F) vs. B using patient data. We also performed an equilibrium binding assay in vitro. Results Some of the B/F vs. B plots of the daily variation showed an approximately linear relationship, while the Scatchard plots of in vitro data became curvilinear. Conclusion Our study suggests that the one-site (high-affinity site) of anti-insulin antibodies accounts, for the most part, for insulin pharmacokinetics within physiological insulin concentrations. Supplementary Information The online version contains supplementary material available at 10.1007/s13340-023-00641-1.
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Affiliation(s)
- Hiroyuki Asaka
- Division of Endocrine and Diabetes, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641 Japan
- Daitoku Internal Medicine and Diabetes Clinic, 2-570 Uneda-higashi, Kanazawa, Ishikawa 920-0344 Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa, 920-1192 Japan
| | - Daisuke Chujo
- Center for Clinical Research, Toyama University Hospital, Sugitani 2630, Toyama, 930-0194 Japan
| | - Mitsuhiro Kometani
- Division of Endocrine and Diabetes, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641 Japan
| | - Mikiya Usukura
- Internal Medicine, Houju Memorial Hospital, 11-71 Midorigaoka, Nomi, Ishikawa 923-1226 Japan
| | - Kunimasa Yagi
- Center for Clinical Genomics, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Ishikawa 920-0293 Japan
| | - Ko Aiga
- Department of Health Promotion and Medicine of the Future, Graduate School of Medicine, Kanazawa University, Kanazawa, 920-8541 Japan
| | - Takashi Yoneda
- Division of Endocrine and Diabetes, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641 Japan
- Department of Health Promotion and Medicine of the Future, Graduate School of Medicine, Kanazawa University, Kanazawa, 920-8541 Japan
- Faculty of Transdisciplinary Sciences, Institute of Transdisciplinary Sciences, Kanazawa University, Kanazawa, 920-1192 Japan
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Saba L, Fatica EM, Orandi AB, Pittock ST, Creo AL. Exogenous Insulin Antibody Syndrome in a Pediatric Patient: Successful Treatment with Mycophenolate Mofetil. Horm Res Paediatr 2023; 97:303-310. [PMID: 37660694 DOI: 10.1159/000531767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/21/2023] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION Exogenous insulin antibody syndrome (EIAS) rarely occurs in type 1 diabetes and should be considered in those with blood glucose levels outside the target range requiring greater than 2 units/kg/day of insulin without obesity. We describe the novel treatment of this condition using mycophenolate mofetil monotherapy in a pediatric patient in the outpatient setting. CASE PRESENTATION A 17-year-old Caucasian male with type 1 diabetes experienced an abrupt increase in insulin requirements from 1.7 to 3.3 units/kg/day. Total insulin level was 7 µIU/mL with free insulin of 4.8 µIU/mL (68% of the total insulin), suggesting the presence of insulin antibodies. Switching from insulin aspart to glulisine was unsuccessful as insulin requirements increased to 4.4 units/kg/day. Treatment with oral mycophenolate mofetil decreased insulin requirements to 1.4 units/kg/day after 7 months. Total and free insulin levels improved to 5.2 and 4.6 µIU/mL, respectively (free insulin was 88% of total insulin). No adverse effects were encountered. CONCLUSION Mycophenolate mofetil monotherapy is successful in safely treating EIAS in a pediatric patient.
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Affiliation(s)
- Leslie Saba
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Erica M Fatica
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir B Orandi
- Division of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Siobhan T Pittock
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana L Creo
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
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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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7
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Al-Beltagi M, Bediwy AS, Saeed NK. Insulin-resistance in paediatric age: Its magnitude and implications. World J Diabetes 2022; 13:282-307. [PMID: 35582667 PMCID: PMC9052009 DOI: 10.4239/wjd.v13.i4.282] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/12/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
Insulin resistance (IR) is insulin failure in normal plasma levels to adequately stimulate glucose uptake by the peripheral tissues. IR is becoming more common in children and adolescents than before. There is a strong association between obesity in children and adolescents, IR, and the metabolic syndrome components. IR shows marked variation among different races, crucial to understanding the possible cardiovascular risk, specifically in high-risk races or ethnic groups. Genetic causes of IR include insulin receptor mutations, mutations that stimulate autoantibody production against insulin receptors, or mutations that induce the formation of abnormal glucose transporter 4 molecules or plasma cell membrane glycoprotein-1 molecules; all induce abnormal energy pathways and end with the development of IR. The parallel increase of IR syndrome with the dramatic increase in the rate of obesity among children in the last few decades indicates the importance of environmental factors in increasing the rate of IR. Most patients with IR do not develop diabetes mellitus (DM) type-II. However, IR is a crucial risk factor to develop DM type-II in children. Diagnostic standards for IR in children are not yet established due to various causes. Direct measures of insulin sensitivity include the hyperinsulinemia euglycemic glucose clamp and the insulin-suppression test. Minimal model analysis of frequently sampled intravenous glucose tolerance test and oral glucose tolerance test provide an indirect estimate of metabolic insulin sensitivity/resistance. The main aim of the treatment of IR in children is to prevent the progression of compensated IR to decompensated IR, enhance insulin sensitivity, and treat possible complications. There are three main lines for treatment: Lifestyle and behavior modification, pharmacotherapy, and surgery. This review will discuss the magnitude, implications, diagnosis, and treatment of IR in children.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Egypt
- Department of Pediatrics, University Medical Center, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Disease, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
- Department of Pulmonology, University Medical Center, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Manama 12, Bahrain
- Microbiology Section, Department of Pathology, Irish Royal College of Surgeon, Busaiteen 15503, Bahrain
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Klainbart S, Segev G, Kelmer E, Chen H. Therapeutic plasma exchange for the management of a type III hypersensitivity reaction and suspected immune-mediated vasculitis assumed to be caused by human albumin administration in a dog. J Vet Emerg Crit Care (San Antonio) 2022; 32:532-538. [PMID: 35234339 DOI: 10.1111/vec.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 11/07/2020] [Accepted: 11/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the successful treatment of a life-threatening type III hypersensitivity reaction suspected to have been related to human serum albumin (HSA) administration in a dog with therapeutic plasma exchange (TPE). CASE SUMMARY A 3-year-old neutered male mixed breed dog was suspected to have developed immune-mediated vasculitis 2 weeks after the administration of HSA (740 mg/kg) for the management of hypoalbuminemia resulting from septic peritonitis. The dog was presented with fever, edema, hypoalbuminemia (26 g/L [2.6 g/dL]; reference interval, 30-44 g/L [3.0-4.4 g/dL]), and coagulopathy. The dog was treated with fresh frozen plasma (FFP) and glucocorticoids but remained hypoalbuminemic (18 g/L [1.8 g/dL]) and developed acute kidney injury (AKI). Over 4 days, 3 TPE treatments were performed, with a total of 2.7 plasma volumes exchanged. Replacement fluids consisted of a combination of FFP, hydroxyethyl starch 6%, and 0.9% saline solution. Following TPE treatments, serum albumin concentration increased (from 18 g/L [1.8 g/dL] to 25 g/L [2.5 g/dL]), serum creatinine concentration decreased (from 340 μmol/L [3.9 mg/dL] to 87 μmol/L [0.98 mg/dL]), and clotting times normalized (activated partial thromboplastin time decreased from 33 seconds to 14.5 seconds). There was a gradual but consistent clinical improvement of the edema and overall demeanor of the dog. No significant adverse effects were noted during the TPE treatments, and the dog was discharged after 8 days of hospitalization. Following discharge, the dog had complete clinical resolution of edema and AKI. NEW/UNIQUE INFORMATION: This is the first report describing successful use of TPE for the management of an immune-mediated reaction (type III hypersensitivity) following HSA administration.
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Affiliation(s)
- Sigal Klainbart
- Department of Small Animal Emergency and Critical Care, The Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Gilad Segev
- Department of Small Animal Internal Medicine, The Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Efrat Kelmer
- Department of Small Animal Emergency and Critical Care, The Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Hilla Chen
- Department of Small Animal Internal Medicine, The Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
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Boro H, Gupta U, Singh C, Malhotra R, Khadgawat R. Continuous glucose monitoring and Rituximab treatment in insulin autoimmune syndrome. Diabetes Metab Syndr 2021; 15:102294. [PMID: 34562871 DOI: 10.1016/j.dsx.2021.102294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Insulin autoimmune syndrome (IAS) or Hirata's disease is a rare cause of hypoglycemia. It is characterized by hyperinsulinemic hypoglycemia, elevated insulin autoantibody titers, no prior exposure to exogenous insulin and no pathological abnormalities of pancreatic islets. Hypoglycemia usually occurs in the post prandial and post absorptive state. Most cases of IAS are self-limiting, with resolution of symptoms within six months to one year. In intractable cases, treatment modalities include low-carbohydrate meals; acarbose; diazoxide; glucocorticoids; immune-suppressants like Azathioprine, cyclophosphamide, mycophenolate mofetil; plasmapheresis and partial pancreatectomy. Rituximab, an anti CD20 monoclonal antibody, was first used in 2016 in a patient with IAS who did not respond to glucocorticoids. Subsequently, there have been three more case reports of IAS where Rituximab was used along with other modalities of treatment. Here, we report the case of a 64-year old Asian Indian woman who presented with recurrent episodes of severe post prandial hypoglycemia and was diagnosed with insulin autoimmune syndrome. She was managed with continuous glucose monitoring and two doses of Rituximab 10 weeks apart, that resulted in resolution of hypoglycemia. This case report underlies the role of Rituximab as a first line agent for treatment of hypoglycemia in IAS.
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Affiliation(s)
- Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Uttio Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Charandeep Singh
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rakhi Malhotra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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10
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Brooks D, Grewal P, Baine I, Arinsburg SA, Maximos S, Shah NA. Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies. AACE Clin Case Rep 2021; 7:307-309. [PMID: 34522770 PMCID: PMC8426605 DOI: 10.1016/j.aace.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objective Insulin antibody (IA)-mediated insulin resistance (IR) is a rare condition for which immunosuppressive regimens have been described. However, these raise the risk of infection, and the drugs may not be effectively metabolized in patients with liver disease. A 61-year old male with type 2 diabetes mellitus and antibody-mediated IR who required >800 units of daily insulin presented with acute decompensation of his preexisting cirrhosis from recurrent diabetic ketoacidosis. Laboratory tests confirmed an IA level of >625 μU/mL (reference: <5.0 μU/mL). Methods Centrifugal plasmapheresis and mycophenolate mofetil (MMF) were used to treat the patient to achieve glycemic control. Continuous glucose monitoring was implemented to monitor glycemic control pre- and posttherapy. Laboratory evaluation included levels of IA, C-peptide, insulin-like growth factor-1, growth hormone, salivary cortisol, zinc transporter 8, glutamic acid decarboxylase 65-kilodalton isoform antibody, and islet-cell antibodies. Results We initiated MMF followed by 5 sessions of plasmapheresis, leading to an overall 77.3% reduction from pretherapy insulin requirements after 6 months without further episodes of diabetic ketoacidosis or infection. The cirrhosis stabilized, and there was an improvement in HbA1C from 8.7% (72 mmol/mol) to 6.6% (49 mmol/mol) and time in euglycemic range from 30% to 61%. Conclusion This is the first report of MMF and centrifugal plasmapheresis use to mitigate the effects of IA-mediated IR in a patient with cirrhosis. We recommend further studies to determine the utility of this treatment to improve care for patients at high risk for IA-mediated IR.
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Key Words
- CGM, continuous glucose monitoring
- DKA, diabetic ketoacidosis
- FSG, fingerstick glucose
- IA, insulin antibody
- IR, insulin resistance
- MELD, Model for End-Stage Liver Disease
- MMF, mycophenolate mofetil
- T2DM, type 2 diabetes mellitus
- TDD, total daily dose
- U-500, concentrated human regular insulin 500 U/mL
- insulin antibodies
- insulin resistance
- mycophenolate mofetil
- plasmapheresis
- type 2 diabetes
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Affiliation(s)
- Danielle Brooks
- Division of Endocrinology, Diabetes and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Priya Grewal
- Division of Liver Diseases and Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ian Baine
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suzanne A Arinsburg
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Nirali A Shah
- Division of Endocrinology, Diabetes and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York
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Takeuchi T, Hirota Y, Nakagawa Y, Matsuoka A, Hamaguchi T, Okada Y, Sakaguchi K, Ogawa W, Koga M. Glycated albumin (GA) and the GA/HbA1c ratio are higher in diabetic patients positive for insulin antibodies with high binding capacity and low affinity. Diabetol Int 2021; 13:226-231. [DOI: 10.1007/s13340-021-00528-z] [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: 03/09/2021] [Accepted: 08/05/2021] [Indexed: 11/30/2022]
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12
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Dharmaputra RK, Wan KL, Samad N, Herath M, Wong J, Sarlos S, Holdsworth SR, Naderpoor N. A novel approach to a rare case of non-islet cell hypoglycaemia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210040. [PMID: 34236039 PMCID: PMC8284944 DOI: 10.1530/edm-21-0040] [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: 05/12/2021] [Accepted: 06/14/2021] [Indexed: 12/24/2022] Open
Abstract
SUMMARY Insulin autoimmune syndrome (IAS) is a rare cause of non-islet cell hypoglycaemia. Treatment of this condition is complex and typically involves long-term use of glucocorticoids. Immunotherapy may provide an alternative in the management of this autoimmune condition through the suppression of antibodies production by B-lymphocyte depletion. We present a case of a 62-year-old male, with refractory hypoglycaemia initially presenting with hypoglycaemic seizure during an admission for acute psychosis. Biochemical testing revealed hypoglycaemia with an inappropriately elevated insulin and C-peptide level and no evidence of exogenous use of insulin or sulphonylurea. Polyethylene glycol precipitation demonstrated persistently elevated free insulin levels. This was accompanied by markedly elevated anti-insulin antibody (IA) titres. Imaging included CT with contrast, MRI, pancreatic endoscopic ultrasound and Ga 68-DOTATATE position emission tomography (DOTATATE PET) scan did not reveal islet cell aetiology for hyperinsulinaemia. Maintenance of euglycaemia was dependent on oral steroids and dextrose infusion. Complete resolution of hypoglycaemia and dependence on glucose and steroids was only achieved following treatment with plasma exchange and rituximab. LEARNING POINTS Insulin autoimmune syndrome (IAS) should be considered in patients with recurrent hyperinsulinaemic hypoglycaemia in whom exogenous insulin administration and islet cell pathologies have been excluded. Biochemical techniques play an essential role in establishing high insulin concentration, insulin antibody titres, and eliminating biochemical interference. High insulin antibody concentration can lead to inappropriately elevated serum insulin levels leading to hypoglycaemia. Plasma exchange and B-lymphocyte depletion with rituximab and immunosuppression with high dose glucocorticoids are effective in reducing serum insulin levels and hypoglycaemia in insulin autoimmune syndrome (IAS). Based on our observation, the reduction in serum insulin level may be a better indicator of treatment efficacy compared to anti-insulin antibody (IA) titre as it demonstrated greater correlation to the frequency of hypoglycaemia and to hypoglycaemia resolution.
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Affiliation(s)
- R K Dharmaputra
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
| | - K L Wan
- Monash Health Pathology, Monash Health, Victoria, Australia
| | - N Samad
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
| | - M Herath
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - J Wong
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Department of Endocrinology, Monash Health, Victoria, Australia
| | - S Sarlos
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Department of Endocrinology, Monash Health, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Victoria, Australia
| | - S R Holdsworth
- Department of Immunology, Monash Health, Victoria, Australia
| | - N Naderpoor
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
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13
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Zhuang Y, Wei X, Yu Y, Wang D. Exogenous insulin antibody syndrome treated with plasma exchange after an incomplete response to immunosuppressive therapy. J Clin Apher 2021; 36:664-667. [PMID: 34013991 PMCID: PMC8453898 DOI: 10.1002/jca.21905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 04/20/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
A 43‐year‐old man with a 23‐year history of type II diabetes presented with uncontrolled hyperglycemia with frequent episodes of ketoacidosis. He was diagnosed with exogenous insulin antibody syndrome, and received high‐dose methylprednisolone to treat insulin resistance. Ketoacidosis relapsed 2 years later, and the patient showed an incomplete response to glucocorticoids. We decided to administer therapeutic plasma exchange, which resulted in rapid lowering of the daily insulin requirement and improved glycemic control.
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Affiliation(s)
- Yuan Zhuang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xudong Wei
- Department of Endocrinology, First Medical Center of Chinese PLA General Hospital, Beijing, China.,Department of Endocrinology, TCM Hospital of Shi Jia Zhuang City, Shijiazhuang, Hebei, China
| | - Yang Yu
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Deqing Wang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
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14
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Li Z, Yi D, Zheng L, Li S, Fang W, Wang C. Analysis of the clinical characteristics of insulin autoimmune syndrome induced by exogenous insulin in diabetic patients. Diabetol Metab Syndr 2021; 13:38. [PMID: 33827670 PMCID: PMC8028117 DOI: 10.1186/s13098-021-00658-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The exact incidence, clinical features and uniform diagnostic criteria of exogenous insulin autoimmune syndrome (EIAS) are still unclear. The purpose of this study is to explore the clinical characteristics of EIAS and to provide a structural approach for clinical diagnosis, treatment and prevention. METHODS The literature on EIAS in Chinese and English from 1970 to 2020 was collected for retrospective analysis. RESULTS A total of 122 patients (33 males and 73 females) were included in the study with a median age of 67 years (range 14-86) and a median HbA1c of 7.7%. EIAS mainly occurred in type 2 diabetes mellitus patients using premixed insulin. Symptoms manifested were hypoglycemia in 86.54%, recurrent episodes of symptomatic hypoglycemia in 35.58%, nocturnal hypoglycemia along with daytime hyperglycemia in 21.15% and recurrent hypoglycemia after discontinued insulin in 64.43%. The onset of symptoms occurred at night, in the early morning or during fasting, ranging from a few days to 78 months after the administration of insulin. The mean blood glucose level during the hypoglycemic phase was 2.21 mmol/L (range 1-3.4), and the serum insulin levels were mainly ≥ 100 U/mL and were associated with low C-peptide levels (≤ 10 ng/ml). Insulin autoantibodies (IAAs) were positive in all EIAS patients. The 75-g extended oral glucose tolerance test (OGTT) mainly showed a diabetic curve. Pancreatic imaging was unremarkable. Withdrawal of insulin alone or combination of oral hypoglycemic agents or replacement of insulin formulations or with corticosteroid treatment eliminated hypoglycemia in a few days to 3 months. IAA turned negative in 6 months (median, range 1-12). No hypoglycemia episodes were observed at a median follow-up of 6 months (range 0.5-60). CONCLUSIONS EIAS is an autoimmune disease caused by insulin-binding antibodies in susceptible subjects. Insulin antibodies change glucose dynamics and could increase the incidence of hypoglycemic episodes. Detection of insulin antibodies is the diagnostic test. Changing therapeutic modalities reduced the incidence of hypoglycemic episodes.
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Affiliation(s)
- Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, Changsha, 410013, Hunan, China
| | - Dan Yi
- Drug Clinical Trial Center, Zhuzhou Central Hospital, Zhuzhou, China
| | - Lijuan Zheng
- Xiangya School of Pharmaceutical Science, Central South University, Changsha, China
| | - Shiran Li
- Xiangya School of Pharmaceutical Science, Central South University, Changsha, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, Changsha, 410013, Hunan, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, Changsha, 410013, Hunan, China.
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15
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Ahmed M, Subbalaxmi MVS, Anne B, Deme S. Recurrent Diabetic Ketoacidosis and Extreme Insulin Resistance Due to Anti-Insulin Antibodies: Response to Immunosuppression and Plasma Exchange. Diabetes Technol Ther 2021; 23:227-229. [PMID: 33016111 DOI: 10.1089/dia.2020.0438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Anti-insulin antibodies (IAs) in patients with insulin-treated diabetes, though common, correlate poorly with glycemic control, insulin requirement, and insulin resistance. We are hereby reporting the clinical course and challenges in the management of a 70-year-old man who had severe insulin resistance as evidenced by recurrent diabetic ketoacidosis and poor glycemic control despite treatment with >9 U of insulin/kg body weight per day. He was found to have anti-IAs and responded clinically to plasmapheresis and immunosuppression with mycophenolate mofetil and prednisolone. Improved glycemic control correlated well with falling titers of antibodies. This case emphasizes that clinicians should be alert to the possibility of insulin resistance due to anti-IAs and the role of immunosuppression and plasmapheresis in such cases.
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Affiliation(s)
- Maaz Ahmed
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, India
| | | | - Beatrice Anne
- Department of Endocrinology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Swaroopa Deme
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, India
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16
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Ashraf A, Palakkott A, Ayoub MA. Anti-Insulin Receptor Antibodies in the Pathology and Therapy of Diabetes Mellitus. Curr Diabetes Rev 2021; 17:198-206. [PMID: 32496987 DOI: 10.2174/1573399816666200604122345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 11/22/2022]
Abstract
Diabetes mellitus (DM) is recognized as the most common and the world's fastest-growing chronic disease with severe complications leading to increased mortality. Many strategies exist for the management of DM and its control, including treatment with insulin and insulin analogs, oral hypoglycemic therapy such as insulin secretion stimulators and insulin sensitizers, and diet and physical training. Over the years, many types of drugs and molecules with an interesting pharmacological diversity have been developed and proposed for their anti-diabetic potential. Such molecules target diverse key receptors, enzymes, and regulatory/signaling proteins known to be directly or indirectly involved in the pathophysiology of DM. Among them, insulin receptor (IR) is undoubtedly the target of choice for its central role in insulin-mediated glucose homeostasis and its utilization by the major insulin-sensitive tissues such as skeletal muscles, adipose tissue, and the liver. In this review, we focus on the implication of antibodies targeting IR in the pathology of DM as well as the recent advances in the development of IR antibodies as promising anti-diabetic drugs. The challenge still entails development of more powerful, highly selective, and safer anti-diabetic drugs.
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Affiliation(s)
- Arshida Ashraf
- Department of Biology, College of Science, The United Arab Emirates University (UAEU), PO Box 15551, Al Ain, United Arab Emirates
| | - Abdulrasheed Palakkott
- Department of Biology, College of Science, The United Arab Emirates University (UAEU), PO Box 15551, Al Ain, United Arab Emirates
| | - Mohammed Akli Ayoub
- Department of Biology, College of Science, The United Arab Emirates University (UAEU), PO Box 15551, Al Ain, United Arab Emirates
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17
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Boro H, Gupta U, Singh C, Malhotra R, Khadgawat R. Insulin Autoimmune Syndrome - A Case Series. EUROPEAN ENDOCRINOLOGY 2020; 16:168-171. [PMID: 33117451 DOI: 10.17925/ee.2020.16.2.168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/27/2020] [Indexed: 11/24/2022]
Abstract
Insulin autoimmune syndrome, or Hirata's disease, is a rare cause of hypoglycaemia. It is characterised by spontaneous episodes of hypoglycaemia, without any exposure to exogenous insulin. The majority of cases are seen in the Japanese population and it is rarely found to affect other ethnicities. The recognition of this disease is important to avoid unnecessary investigations and procedures. Here, we report two cases of insulin autoimmune syndrome, which were diagnosed and managed in our institute.
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Affiliation(s)
- Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Uttio Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Charandeep Singh
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rakhi Malhotra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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18
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19
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Robbins DJ, Taylor NE, Narayanan D, Hess AS, Rose WN. Therapeutic plasma exchange for exogenous insulin antibody syndrome in combined variable immunodeficiency: a case report. J Clin Apher 2020; 35:128-130. [PMID: 31981239 DOI: 10.1002/jca.21769] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/12/2022]
Abstract
A 32-year-old male with type I diabetes presented with profound hypoglycemia due to exogenous insulin antibody syndrome in the setting of newly-diagnosed common variable immunodeficiency. Immunomodulatory therapy was not initially effective, but after the initiation of plasma exchange hypoglycemia resolved, and glucose lability improved.
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Affiliation(s)
- Daniel J Robbins
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Natalie E Taylor
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Damodaran Narayanan
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Aaron S Hess
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, WI.,Department of Anesthesiology, University of Wisconsin Hospital and Clinics, Madison, WI
| | - William N Rose
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
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20
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Antibody-Mediated Extreme Insulin Resistance: The Importance of Pre-Treatment Screening. Case Rep Endocrinol 2019; 2019:8562546. [PMID: 31827945 PMCID: PMC6885187 DOI: 10.1155/2019/8562546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/15/2019] [Indexed: 01/06/2023] Open
Abstract
We report the case of a 56 year-old Hispanic male with a 10-year history of type 2 diabetes who presented with abrupt onset of hyperglycemia resistant to escalating doses of intravenous insulin infusion (>2500 units daily). He was diagnosed with antibody-mediated insulin resistance given the presence of hyperglycemia despite receiving >200 units insulin/day, a lack of identifiable precipitants for diabetic ketoacidosis or hyperosmolar hyperglycemic state, and elevated insulin antibodies. He underwent pre-immunomodulatory therapy screening for infections, rheumatologic disorders, and malignancy, which uncovered a new diagnosis of latent tuberculosis. While concurrently being treated for latent tuberculosis, he successfully responded to immunomodulatory therapy with rituximab, dexamethasone, and cyclophosphamide. Insulin was discontinued completely, and he maintained appropriate glycemic control on oral diabetic agents (metformin and pioglitazone). This case supports the use of immunomodulatory therapy for the treatment of antibody-mediated insulin resistance and highlights the importance of pre-immunomodulatory therapy screening to uncover occult infection or identify underlying neoplastic/rheumatologic disease prior to immunosuppression.
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21
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Church D, Cardoso L, Kay RG, Williams CL, Freudenthal B, Clarke C, Harris J, Moorthy M, Karra E, Gribble FM, Reimann F, Burling K, Williams AJK, Munir A, Jones TH, Führer D, Moeller LC, Cohen M, Khoo B, Halsall D, Semple RK. Assessment and Management of Anti-Insulin Autoantibodies in Varying Presentations of Insulin Autoimmune Syndrome. J Clin Endocrinol Metab 2018; 103:3845-3855. [PMID: 30085133 PMCID: PMC6179165 DOI: 10.1210/jc.2018-00972] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/26/2018] [Indexed: 01/01/2023]
Abstract
Context Insulin autoimmune syndrome (IAS), spontaneous hyperinsulinemic hypoglycemia due to insulin-binding autoantibodies, may be difficult to distinguish from tumoral or other forms of hyperinsulinemic hypoglycemia, including surreptitious insulin administration. No standardized treatment regimen exists. Objectives To evaluate an analytic approach to IAS and responses to different treatments. Design and Setting Observational study in the UK Severe Insulin Resistance Service. Patients Six patients with hyperinsulinemic hypoglycemia and detectable circulating anti-insulin antibody (IA). Main Outcome Measures Glycemia, plasma insulin, and C-peptide concentrations by immunoassay or mass spectrometry (MS). Immunoreactive insulin was determined in the context of polyethylene glycol (PEG) precipitation and gel filtration chromatography (GFC). IA quantification using ELISA and RIA, and IA were further characterized using radioligand binding studies. Results All patients were diagnosed with IAS (five IgG, one IgA) based on a high insulin/C-peptide ratio, low insulin recovery after PEG precipitation, and GFC evidence of antibody-bound insulin. Neither ELISA nor RIA result proved diagnostic for every case. MS provided a more robust quantification of insulin in the context of IA. One patient was managed conservatively, four were treated with diazoxide without sustained benefit, and four were treated with immunosuppression with highly variable responses. IA affinity did not appear to influence presentation or prognosis. Conclusions IAS should be considered in patients with hyperinsulinemic hypoglycemia and a high insulin/C-peptide ratio. Low insulin recovery on PEG precipitation supports the presence of insulin-binding antibodies, with GFC providing definitive confirmation. Immunomodulatory therapy should be customized according to individual needs and clinical response.
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Affiliation(s)
- David Church
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Academic Endocrine Unity, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Richard G Kay
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
| | - Claire L Williams
- Diabetes & Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Bernard Freudenthal
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Catriona Clarke
- Department of Clinical Biochemistry, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Julie Harris
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Myuri Moorthy
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Efthmia Karra
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Fiona M Gribble
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Frank Reimann
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Keith Burling
- Core Biochemical Assay Laboratory, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Alistair J K Williams
- Diabetes & Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Alia Munir
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - T Hugh Jones
- Robert Hague Centre for Diabetes and Endocrinology, Barnsley Hospital, NHS Foundation Trust, Barnsley, United Kingdom
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lars C Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Mark Cohen
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Bernard Khoo
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - David Halsall
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Robert K Semple
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
- University of Edinburgh Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, United Kingdom
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22
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Mkrtumyan A, Romantsova T, Vorobiev S, Volkova A, Vorokhobina N, Tarasov S, Putilovskiy M, Andrianova E, Epstein O. Efficacy and safety of Subetta add-on therapy in type 1 diabetes mellitus: The results of a multicenter, double-blind, placebo-controlled, randomized clinical trial. Diabetes Res Clin Pract 2018; 142:1-9. [PMID: 29807102 DOI: 10.1016/j.diabres.2018.04.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/09/2018] [Accepted: 04/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND To examine efficacy of Subetta as an add-on to insulin therapy in patients with type 1 diabetes mellitus (T1DM) a multicenter, double-blind, placebo-controlled, randomized clinical trial was performed. Derived by technological treatment of antibodies to insulin receptor β-subunit and endothelial NO synthase Subetta was previously proved to activate insulin signaling pathway. METHODS A total of 144 randomized patients with poor glycemic control in basal-bolus insulin regime were included in intention-to-treat analysis in Subetta add-on therapy or placebo (n = 72 in both groups). Hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), basal and prandial insulin doses, number of hypoglycemia episodes confirmed by self-monitoring of blood glucose were recorded for 36 weeks. RESULTS The baseline characteristics of subjects did not differ between the two groups. HbA1c mean (±standard deviation) change was -0.59 ± 0.99% (95% CI -0.84 to -0.37) after 36 weeks in Subetta (vs. -0.20 ± 1.14%; 95% CI -0.44 to 0.11 in placebo; p = 0.028). The rate of overall hypoglycemia events was 7.9 per patient year (95% CI 7.1-8.6) in Subetta group and 7.6 (95% CI 6.9-8.4) in Placebo group (p = 0.63). The basal and total insulin doses did not change at the end of 36 weeks in both groups. CONCLUSIONS Subetta add-on therapy boosting insulin activity and improving glycemic control in patients with T1DM is proved to be beneficial. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01868594.
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Affiliation(s)
- Ashot Mkrtumyan
- Moscow Clinical Scientific and Practical Center named after A.S. Loginov, 86, Enthusiastov Sh., 111123 Moscow, Russian Federation.
| | - Tatyana Romantsova
- Sechenov First Moscow State Medical University, 8-2, Trubetskaya St., 119991 Moscow, Russian Federation.
| | - Sergei Vorobiev
- Rostov State Medical University, 29, Nakhichevan Per., 344022 Rostov-on-Don, Russian Federation.
| | - Anna Volkova
- Pavlov First Saint Petersburg State Medical University, 6-8, Lva Tolstogo St., 197022 Saint Petersburg, Russian Federation.
| | - Natalia Vorokhobina
- Elizavetinskaya Municipal Hospital, 14, Vavilovyh St., 195257 Saint Petersburg, Russian Federation.
| | - Sergey Tarasov
- OOO "NPF "MATERIA MEDICA HOLDING", 9, 3rd Samotyochny Per., 127473 Moscow, Russian Federation.
| | - Mikhail Putilovskiy
- OOO "NPF "MATERIA MEDICA HOLDING", 9, 3rd Samotyochny Per., 127473 Moscow, Russian Federation.
| | - Elena Andrianova
- OOO "NPF "MATERIA MEDICA HOLDING", 9, 3rd Samotyochny Per., 127473 Moscow, Russian Federation.
| | - Oleg Epstein
- The Institute of General Pathology and Pathophysiology, 8, Baltiyskaya St., 125315 Moscow, Russian Federation.
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23
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Hu X, Chen F. Exogenous insulin antibody syndrome (EIAS): a clinical syndrome associated with insulin antibodies induced by exogenous insulin in diabetic patients. Endocr Connect 2018; 7:R47-R55. [PMID: 29233817 PMCID: PMC5776673 DOI: 10.1530/ec-17-0309] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/12/2017] [Indexed: 11/11/2022]
Abstract
Insulin has been used for diabetes therapy and has achieved significant therapeutic effect. In recent years, the use of purified and recombinant human insulin preparations has markedly reduced, but not completely suppressed, the incidence of insulin antibodies (IAs). IAs induced by exogenous insulin in diabetic patients is associated with clinical events, which is named exogenous insulin antibody syndrome (EIAS). The present review is based on our research and summarizes the characterization of IAs, the factors affecting IA development, the clinical significance of IAs and the treatments for EIAS.
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Affiliation(s)
- Xiaolei Hu
- Department of EndocrinologyThe First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
- Department of EndocrinologyShanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fengling Chen
- Department of EndocrinologyShanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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24
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Antibody-Mediated Insulin Resistance: When Insulin and Insulin Receptor Act as Autoantigens in Humans. Can J Diabetes 2016; 40:462-465. [PMID: 27062110 DOI: 10.1016/j.jcjd.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/06/2016] [Accepted: 02/20/2016] [Indexed: 11/22/2022]
Abstract
We report the case of a patient with diabetes presenting a severe insulin-resistance syndrome due to the production of insulin autoantibodies by a lymphocytic lymphoma. We describe the various mechanisms leading to the production of insulin autoantibodies and insulin receptor autoantibodies and review the therapeutic possibilities.
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25
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Takaya M, Nagao M, Takemitsu S, Nakajima Y, Sugihara H, Uchigata Y, Oikawa S. Severe Insulin-resistant Diabetes due to Insulin Antibodies Associated with Eosinophilia. Intern Med 2015; 54:2367-71. [PMID: 26370863 DOI: 10.2169/internalmedicine.54.4022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 66-year-old man with type 2 diabetes on hemodialysis treatment was admitted due to poor glycemic control. His serum insulin level and the (125)I-insulin binding rate were extremely high with an increased eosinophil count, although he did not have an allergic reaction to insulin or an elevation of specific IgE for human insulin. A Scatchard analysis revealed that the patient's insulin antibodies had a low affinity constant and a high binding capacity. Prednisolone administration decreased the eosinophil count and (125)I-insulin binding rate; accordingly, the glycemic control improved. Corticosteroid therapy may be a potent therapeutic strategy for insulin antibody-induced severe insulin resistance with eosinophilia.
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Affiliation(s)
- Makiyo Takaya
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, Japan
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ZHANG YIYI, ZHAO TIEYUN. Hypoglycemic coma due to insulin autoimmune syndrome induced by methimazole: A rare case report. Exp Ther Med 2014; 8:1581-1584. [PMID: 25289063 PMCID: PMC4186395 DOI: 10.3892/etm.2014.1964] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 08/15/2014] [Indexed: 02/05/2023] Open
Abstract
Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia characterized by the presence of insulin-binding autoantibodies and fasting or late postprandial hypoglycemia. The number of reports on the association of human leukocyte antigen (HLA) genotype with this disease in adolescents in China is limited. This is the case report of a 17-year-old female patient with Graves' disease who was treated with methimazole (MTZ). After 4 weeks of continuous MTZ treatment, the patient suffered an episode of unconsciousness during the late postprandial phase and was admitted to the hospital, where the blood glucose level was found to be 2.88 mmol/l. The symptoms were relieved following intravenous glucose administration. Imaging studies of the pancreas were unremarkable, but the laboratory investigations on admission revealed high serum levels of total insulin, associated with relatively low levels of free insulin and markedly elevated insulin autoantibody (IAB) levels. HLA testing revealed DRB1*0406/0901 and the patient discontinued MTZ and was prescribed propylthiouracil. During the long-term follow-up, the total insulin and IAB levels gradually declined. There was no other episode of hypoglycemia. Therefore, in adolescents with Graves' disease receiving antithyroid treatment with MTZ who experience hypoglycemia, the IAB levels should be assessed to exclude or confirm IAS as the underlying cause.
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Affiliation(s)
- YIYI ZHANG
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - TIEYUN ZHAO
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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Fujikawa T, Imbe H, Date M, Go Y, Kitaoka H. Severe insulin allergy successfully treated with continuous subcutaneous insulin infusion. Diabetes Res Clin Pract 2012; 97:e31-3. [PMID: 22609054 DOI: 10.1016/j.diabres.2012.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 04/30/2012] [Indexed: 11/25/2022]
Abstract
Insulin allergy is a rare complication of insulin therapy. Proper management, though difficult, is critical. Here, we report the case of a patient with type 2 diabetes and insulin allergy, successfully treated with continuous subcutaneous insulin infusion (CSII).
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Affiliation(s)
- Tatsuya Fujikawa
- Department of Internal Medicine, Seikeikai Hospital, 4-2-10 Koryo-nakamachi, Sakai, Osaka 590-0024, Japan.
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28
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A case of glycemic instability and insulin allergy due to anti-insulin antibodies in a patient with type 2 diabetes. Diabetol Int 2012. [DOI: 10.1007/s13340-012-0077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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29
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Semple RK, Savage DB, Cochran EK, Gorden P, O'Rahilly S. Genetic syndromes of severe insulin resistance. Endocr Rev 2011; 32:498-514. [PMID: 21536711 DOI: 10.1210/er.2010-0020] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Insulin resistance is among the most prevalent endocrine derangements in the world, and it is closely associated with major diseases of global reach including diabetes mellitus, atherosclerosis, nonalcoholic fatty liver disease, and ovulatory dysfunction. It is most commonly found in those with obesity but may also occur in an unusually severe form in rare patients with monogenic defects. Such patients may loosely be grouped into those with primary disorders of insulin signaling and those with defects in adipose tissue development or function (lipodystrophy). The severe insulin resistance of both subgroups puts patients at risk of accelerated complications and poses severe challenges in clinical management. However, the clinical disorders produced by different genetic defects are often biochemically and clinically distinct and are associated with distinct risks of complications. This means that optimal management of affected patients should take into account the specific natural history of each condition. In clinical practice, they are often underdiagnosed, however, with low rates of identification of the underlying genetic defect, a problem compounded by confusing and overlapping nomenclature and classification. We now review recent developments in understanding of genetic forms of severe insulin resistance and/or lipodystrophy and suggest a revised classification based on growing knowledge of the underlying pathophysiology.
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Affiliation(s)
- Robert K Semple
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Abstract
BACKGROUND Insulin allergy is a rare complication of insulin use. Localized lipoatrophy is also known to occur following subcutaneous injections of insulin. CASE REPORT A 53-year-old non-obese female patient with Type 2 diabetes displayed local allergic-type symptoms to all available insulin preparations. This was complicated by the development of severe lipoatrophy on her abdominal and thigh injection sites and subsequently resulted in suboptimal glycaemic control. CONCLUSIONS Whilst uncommon, insulin allergy and lipoatrophy can cause major problems in diabetic management. Potential pathophysiological mechanisms and a stepwise approach to management are discussed.
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Affiliation(s)
- A N Tavare
- Department of Diabetes and Endocrinology, The Hillingdon Hospital, Uxbridge, UK.
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Torosantucci R, Kukrer B, Mero A, Van Winsen M, Tantipolphan R, Jiskoot W. Plain and mono-pegylated recombinant human insulin exhibit similar stress-induced aggregation profiles. J Pharm Sci 2011; 100:2574-85. [PMID: 21344414 DOI: 10.1002/jps.22523] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/19/2011] [Accepted: 01/31/2011] [Indexed: 11/10/2022]
Abstract
PEGylation has been suggested to improve the stability of insulin, but evidence for that is scarce. Here, we compared the forced aggregation behavior of insulin and mono-PEGylated insulin. Therefore, recombinant human insulin was conjugated on lysine B29 with 5-kDa PEG. PEG-insulin was purified by size-exclusion chromatography (SEC) and characterized by mass spectrometry (MS). Next, insulin and PEG-insulin were subjected to heating at 75 °C, metal-catalyzed oxidation, and glutaraldehyde cross-linking. The products were characterized physicochemically by complementary analytical methods. Mono-PEGylation of insulin was confirmed by SEC and MS. Under each of the applied stress conditions, insulin and PEG-insulin showed comparable degradation profiles. All the stressed samples showed submicron aggregates in the size range between 50 and 500 nm. Covalent aggregates and conformational changes were found for both oxidized products. Insulin and its PEGylated counterpart also exhibited similar characteristics when exposed to heat stress, that is, slightly changed secondary and tertiary structures, covalent aggregates with partially intact epitopes, and separation of chain A from chain B. Both glutaraldehyde-treated insulin and PEG-insulin contained covalent and noncovalent aggregates with intact epitopes, showed partially perturbed secondary structure, and substantial loss of tertiary structure. From these results, we conclude that PEGylation does not protect insulin against forced aggregation.
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Affiliation(s)
- Riccardo Torosantucci
- Division of Drug Delivery Technology, Leiden/Amsterdam Center for Drug Research, Leiden University, Leiden 2300 RA, The Netherlands
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Frequent reoccurrence of hypoglycemia in a type 2 diabetic patient with insulin antibodies. Mol Diagn Ther 2010; 14:237-41. [PMID: 20799766 DOI: 10.1007/bf03256379] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Insulin antibody (IAb) may be produced in patients receiving long-term, animal-derived insulin, leading to insulin resistance or hypoglycemia. There have been very few reports of hypoglycemia caused by IAb in patients taking recombinant human insulin. CASE REPORT We report the case of an 82-year-old male patient with type 2 diabetes mellitus who suffered repeated episodes of severe hypoglycemia-related symptoms (including coma) prior to admission. The patient had been taking Novolin 30R, a premixed human insulin. The patient's IAb level was markedly elevated, and hypoglycemia caused by recombinant human insulin treatment-induced IAb production was diagnosed. Acarbose and metformin were prescribed, and the patient recovered uneventfully. The patient ceased taking these medications, and he was subsequently treated with recombinant human insulin to combat hyperglycemia. This was followed by reoccurrence of hypoglycemic coma. The patient was advised to avoid taking recombinant human insulin for the rest of his life and to control hyperglycemia with acarbose and metformin. CONCLUSIONS Although rare, hypoglycemia caused by recombinant human insulin-induced IAb production should be considered in patients with type 2 diabetes who experience repeated episodes of hypoglycemia.
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Ovalle F. Clinical approach to the patient with diabetes mellitus and very high insulin requirements. Diabetes Res Clin Pract 2010; 90:231-42. [PMID: 20724017 DOI: 10.1016/j.diabres.2010.06.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 06/10/2010] [Accepted: 06/21/2010] [Indexed: 12/26/2022]
Abstract
A number of patients with diabetes require very high (> 2 Ukg⁻¹ day⁻¹), or extremely high (> 3 Ukg⁻¹ day⁻¹), insulin doses for the management of their hyperglycemia. Unfortunately, many of the physicians who treat these patients limit themselves to prescribing ever higher doses of insulin, without questioning why. Furthermore, when the insulin requirements get to be extreme, demanding an explanation, clinicians are frequently lost in a sea of literature where there is not a single paper dealing with this problem systematically. A systematic approach to the evaluation of these patients is necessary to facilitate an appropriate diagnosis, select the most reasonable therapy, and hopefully improve the long-term outcome of these patients. This manuscript intends to provide the clinician with a review of the literature pertinent for the differential diagnosis, work-up, and management of these patients. We will review the definitions of insulin sensitivity during normality, the various degrees or categories of insulin resistance, and the expected insulin requirements during each of these states. Subsequently, we propose a simple alphabetic mnemonic approach to help remember the differential diagnosis, and a clinical algorithm to help guide the work-up of these patients. Lastly, we briefly discuss general management considerations in these conditions.
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Affiliation(s)
- F Ovalle
- UAB Comprehensive Diabetes Center, Division of Endocrinology, Diabetes & Metabolism, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35294, USA.
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Hirota Y, Ogawa W, Murawaki A, Nishiumi T, Komada H, Miyake K, Sakaguchi K, Kasuga M. Deterioration of glycaemic control associated with anti-insulin antibodies likely induced by health supplements. Diabet Med 2009; 26:948-51. [PMID: 19719720 DOI: 10.1111/j.1464-5491.2009.02779.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bayraktar F, Akinci B, Demirkan F, Yener S, Yesil S, Kirmaz C, Comlekci A. Serum sickness-like reactions associated with type III insulin allergy responding to plasmapheresis. Diabet Med 2009; 26:659-60. [PMID: 19538244 DOI: 10.1111/j.1464-5491.2009.02733.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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