Generalised allergy to porcine and bovine monocomponent insulins

100 years on: the impact of the discovery of insulin on clinical outcomes

Throughout history, up to the early part of the 20th century, diabetes has been a devastating disorder, particularly when diagnosed in childhood when it was usually fatal. Consequently, the successful pancreatic extraction of insulin in 1921 was a miraculous, life-changing advance. In this review, the truly transformative effect that insulin has had on the lives of people with type 1 diabetes and on those with type 2 diabetes who are also dependent on insulin is described, from the time of its first successful use to the present day. We have highlighted in turn how each of the many facets of improvements over the last century, from advancements in the properties of insulin and its formulations to the evolution of different methods of delivery, have led to continued improvement in clinical outcomes, through the use of illustrative stories from history and from our own clinical experiences. This review concludes with a brief look at the current challenges and where the next century of technological innovation in insulin therapy may take us.

Systemic allergy to endogenous insulin during therapy with recombinant DNA (rDNA) insulin

BACKGROUND

Clinically significant allergic reactions with insulin therapy are known to occur. There have been rare reports of allergic reactions to endogenously secreted insulin manifested as insulin resistance. No reports of systemic or local allergic reactions to endogenous insulin have previously been cited, and no immunologic reactions to endogenous insulin have been reported during therapy with recombinant (rDNA) insulin.

METHODS

We report a case in which the patient, a 28-year-old black woman who initially presented with gestational onset diabetes but postpartum continued to require insulin, developed generalized allergic reactions during therapy with subcutaneously injected rDNA insulin. Similar reactions occurred with sulfonylurea therapy. She was unable to tolerate any pharmacologic therapy for diabetes without concurrent use of at least 10 mg of prednisone per day.

RESULTS

Skin testing with the insulin preparations were positive, while skin testing to the sulfonylurea hypoglycemic agents were negative. IgE antibodies to insulin where present in high titer. Oral challenge to sulfonylurea hypoglycemic agents produced generalized urticarial reactions coinciding with time of peak insulin secretion. Oral challenge to other medications containing sulfa produced no adverse reaction. Biphasic hypersensitivity reactions occurred during attempts at desensitization which were futile without simultaneous glucocorticoid therapy.

CONCLUSIONS

This is the first report of local and systemic allergic reactions to endogenously secreted insulin in association with rDNA insulin therapy. Although immunologic complications with rDNA therapy appear less frequently than with insulin preparations, this case illustrates the need for continued awareness for potential allergic complications occurring with rDNA insulin therapy.

Allergic reaction to purified pork insulin

A 53-year-old white male diabetic experienced an allergic-like reaction while being switched from non-highly-purified to highly purified pork insulins. The patient, after experiencing his second separate allergic response, came to the emergency room and showed marked improvement when returned to the non-highly-purified insulins he had been taking previously.

An anaphylactic reaction to highly purified pork insulin. Confirmation by RAST and RAST inhibition

We describe a patient who had an anaphylactic reaction to highly purified pork insulin; he was not allergic however to beef insulin. The sensitivity to pork but not to beef insulin was confirmed by skin testing, radioallergosorbent test (RAST) and RAST inhibition. A scheme is suggested for the investigation of such patients.

Diabetes mellitus in childhood

This review has attempted to highlight current views on the aetiology and management of children with type 1 diabetes mellitus. Emphasis has been placed on the management of ketoacidosis, the need for education and the use of home blood glucose monitoring. A perspective on new research direction has been given.