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Liu Y, Ping F, Yu J, Lv L, Zhao Y, Qi M, Li W, Xu L, Yu M, Li M, Zhang H, Li Y. Hypoglycemia Caused by Exogenous Insulin Antibody Syndrome: A Large Single-Center Case Series From China. J Clin Endocrinol Metab 2023; 108:713-717. [PMID: 36219196 DOI: 10.1210/clinem/dgac578] [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: 05/07/2022] [Revised: 09/10/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Exogenous insulin antibody syndrome (EIAS) can lead to unexpected and potentially life-threatening recurrent hypoglycemia. OBJECTIVE We aimed to better define autoimmune hypoglycemia caused by EIAS in patients with diabetes and shed light on the improvements in the identification and intervention for this rare but possibly life-threatening condition. METHODS We summarized the clinical characteristics of autoimmune hypoglycemia caused by EIAS in 23 patients with diabetes. Furthermore, we performed human leukocyte antigen (HLA) genotyping of 10 patients. RESULTS We identified a high frequency of autoimmune comorbidities (21.7%), food or drug allergy (48%), insulin allergy (30%), lipodystrophy at the insulin injection sites (22%), and antinuclear antibodies (25%) in the patients. Alternation between hyperglycemia and hypoglycemia was observed in more than 90% of the patients. Most patients showed a high insulin autoantibody titer (>90%) and inappropriately increased insulin concentration (insulin/C-peptide molar ratio >7, >85%). We detected similar frequencies of DRB1*0405-DQB1*0401 and DRB1*0901-DQB1*0303 compared with previously reported frequencies in type 1 diabetes, and a lower frequency of DRB1*0406 compared with insulin autoimmune syndrome. The spontaneous remission rate exceeded 70%. CONCLUSION Predisposing factors for autoimmune hypoglycemia caused by EIAS include a strong autoimmune background. Susceptible HLA genotypes for type 1 diabetes or insulin autoimmune syndrome might not explain susceptibility to this condition. Additionally, insulin autoantibodies and the insulin/C-peptide molar ratio are reliable screening options. The prognosis for this condition is favorable. Monitoring of insulin and insulin autoantibodies may contribute to treatment effectiveness.
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Affiliation(s)
- Yiwen Liu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jie Yu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lu Lv
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yuan Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Mengya Qi
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lingling Xu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Miao Yu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ming Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Huabing Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Geng L, Diao X, Han H, Lin Y, Liang W, Xu A. Type 1 diabetes complicated with cyclic vomiting syndrome and exogenous insulin antibody syndrome: A case report. Front Endocrinol (Lausanne) 2022; 13:1043301. [PMID: 36440205 PMCID: PMC9684460 DOI: 10.3389/fendo.2022.1043301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/28/2022] [Indexed: 11/11/2022] Open
Abstract
Every fifth individual with type 1 diabetes (T1D) suffers from an additional autoimmune disorder due to shared genetic factors and dysregulated immunity. Here we report an extremely rare case of T1D complicated with cyclic vomiting and hypoglycaemia. A 27-year-old Chinese woman with 14-year history of T1D was periodically hospitalized for severe vomiting of more than 30 times a day without apparent organic causes. The vomiting developed acutely and remitted spontaneously after 2-3 days, followed with intractable hypoglycaemia for another 3-4 days during the hospitalization. A few weeks after discharge, she was admitted once again with the same symptoms and disease course. Cyclic vomiting syndrome (CVS) was diagnosed according to the Rome IV criteria, a system developed to define the functional gastrointestinal disorders. Dynamic association and disassociation of exogenous insulin and insulin antibodies (IAs) were identified in her blood during hypoglycaemia, leading to the diagnosis of exogenous insulin antibody syndrome (EIAS). Treatment with rituximab to suppress the IAs was associated with a striking amelioration of hypoglycaemia. Unexpectedly, the episodes of cyclic vomiting were also dramatically reduced. In conclusion, we identified the first case with alternating CVS and EIAS in the setting of T1D. Dynamic measurements of free and total insulin are helpful for the diagnosis of EIAS. CVS is likely to be a latent autoimmune disorder considering the good response to rituximab treatment.
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Affiliation(s)
- Leiluo Geng
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Xue Diao
- Department of Endocrinology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hao Han
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ying Lin
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Wei Liang
- Department of Endocrinology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- *Correspondence: Wei Liang, ; Aimin Xu,
| | - Aimin Xu
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- *Correspondence: Wei Liang, ; Aimin Xu,
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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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Abstract
RATIONALE Insulin autoimmune syndrome (IAS) is a rare endocrine disease characterized by repeated fasting hypoglycemia or episodes of hypoglycemia late after meals, elevated serum insulin, and positivity for insulin autoantibody (IAA) or insulin receptor antibody (IRA). We summarize the clinical manifestations and treatment experiences of 3 patients with IAS. PATIENT CONCERNS One patient with >20-year history of type 2 diabetes mellitus had irregular episodes of hypoglycemia 2 years of after treatment with insulin. Another patient with a 6-year history of type 2 diabetes mellitus presented irregular episodes of hypoglycemia after 6 months of treatment with insulin. One patient with a history of Graves' disease showed hypoglycemia after administration of thiamazole. DIAGNOSIS Serum islet cell antibody (ICA) and glutamic acid decarboxylase antibody (GADA) were negative, while antibody insulin autoantibodies were positive in all the 3 patients. Two patients demonstrated diabetes mellitus after an oral glucose tolerance test, while one had normal glucose tolerance. Furthermore, serum insulin levels significantly elevated and did not matched C peptide levels. No abnormalities were found on enhanced MRI of the pancreas, and all 3 patients were clinically diagnosed with IAS. INTERVENTIONS In case one, insulin aspart 30 injection was withdrawn after admission. In addition, the patient was prescribed sublingual acarbose 3 times daily. Two weeks after admission, prednisone acetate was administered orally once daily at night. In case 2, insulin aspart 30 injection was withdrawn after admission, the patient was prescribed sublingual acarbose 3 times daily with a meal. Five days after admission, oral prednisone acetate was administered once daily at night. In case 3, oral propylthiouracil was prescribed and thiamazole withdrawn after admission, and the patient consumed an extra meal before sleeping. OUTCOMES At the 3-month follow-up visit, the hypoglycemic episodes had disappeared, serum insulin levels were significantly decreased, and insulin antibody (IA) levels were no longer detectable in all 3 patients. LESSONS For those patients with high-insulin hypoglycemia, IAA should be evaluated if serum insulin concentrations are inconsistent with C peptide levels. Therapeutically, a lower dose of glucocorticoids with more appropriate medication timing can be used to achieve good results.
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Yeung CW, Mak CM, Lam KSL, Tam S. Hypoglycaemia due to autoimmune insulin syndrome in a 78-year-old Chinese man. Br J Biomed Sci 2018. [DOI: 10.1080/09674845.2012.12002442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- C. W. Yeung
- Division of Clinical Biochemistry, Queen Mary Hospital, Hong Kong SAR, China
| | - C. M. Mak
- Division of Clinical Biochemistry, Queen Mary Hospital, Hong Kong SAR, China
- Chemical Pathology Laboratory, Department of Pathology, Princess Margaret Hospital, Hong Kong SAR, China
| | - K. S. L. Lam
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - S. Tam
- Division of Clinical Biochemistry, Queen Mary Hospital, Hong Kong SAR, China
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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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Matsumoto Y, Yamada H, Funazaki S, Suzuki D, Kakei M, Hara K. Effect of Liraglutide on Type B Insulin Resistance Syndrome and Insulin Allergy in Type 2 Diabetes: A Case Report. Diabetes Ther 2017; 8:1191-1194. [PMID: 28836180 PMCID: PMC5630548 DOI: 10.1007/s13300-017-0291-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION The appearance of anti-insulin antibodies or an allergy to insulin occasionally causes clinical problems with glycemic control in insulin users. METHODS In the present report, we describe a therapeutic approach that was employed for a man with type 2 diabetes who had insulin allergy, anti-insulin antibodies, and anti-insulin receptor antibodies that developed during his insulin treatment. RESULTS We started the patient on liraglutide, a glucagon-like peptide-1 receptor agonist, and attained glycemic control without incurring any side effects. Two years after liraglutide induction, his blood glucose was being maintained at a healthy level by liraglutide monotherapy. CONCLUSION Liraglutide may be a therapeutic option for patients with insulin allergy, anti-insulin antibodies, and type B insulin resistance syndrome, as it represents an alternative strategy to insulin.
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Affiliation(s)
- Yuko Matsumoto
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hodaka Yamada
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Shunsuke Funazaki
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Daisuke Suzuki
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Masafumi Kakei
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Kazuo Hara
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
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Chu JP, Zheng XW, Lu J, Zhong JY, Li JL, Xu M, Lin F. Insulin-induced autoimmune syndrome: A case report. Exp Ther Med 2016; 12:3359-3362. [PMID: 27882163 DOI: 10.3892/etm.2016.3767] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 08/25/2016] [Indexed: 12/12/2022] Open
Abstract
Insulin autoimmune syndrome (IAS) is a disease characterized by hyperinsulinemic hypoglycemia associated with autoantibodies against endogenous insulin. A 56-year-old man was admitted to Ningbo First Hospital for the treatment of spontaneous hypoglycemia. He was found to have elevated fasting insulin level (>1,000 mIU/l) and presence of insulin autoantibodies, and after appropriate workup, was diagnosed with IAS. After treating with prednisone for 2 months, his insulin level started decreasing. In patients with repeated hypoglycemia, IAS should be considered in the differential diagnosis. Prednisone may be effective for the treatment of hypoglycemia in patients with IAS.
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Affiliation(s)
- Jian-Ping Chu
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Xiao-Wei Zheng
- School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jie Lu
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jin-Yan Zhong
- School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jia-Lin Li
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Miao Xu
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Fang Lin
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
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Li R, Mao J, Yu K, Wang L, Hu M, Xu L. Medical Nutrition Therapy Is Effective in the Management of Hypoglycemia Caused by Insulin Antibodies: A Case Report and Literature Review. J Am Coll Nutr 2015; 35:86-90. [PMID: 26273793 DOI: 10.1080/07315724.2014.976673] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Autoimmune antibodies, induced by exogenous insulin preparations, may result in labile glucose control and frequent hypoglycemia in some rare cases. In addition to insulin cessation, immune suppressants and/or plasmapheresis have been used as the primary remedies for these patients. Some previous studies also indicate that the condition tends to remit spontaneously after discontinuation of insulin exposure. Because of this, the clinical importance of nutritional interventions and behavioral approaches, which may play a role in ameliorating the symptoms, should also be emphasized. Herein, we report on a 64-year-old man with hypoglycemia induced by insulin antibodies (IAs), whose hypoglycemic symptoms significantly improved after the implementation of nutrition therapy. This rare case expands our knowledge of the management of hypoglycemia, and for the first time highlights the significance of nutritional and lifestyle intervention in treatment of IA-induced hypoglycemia.
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Affiliation(s)
- Rongrong Li
- a Department of Clinical Nutrition, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , CHINA
| | - Jiangfeng Mao
- b Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , CHINA
| | - Kang Yu
- a Department of Clinical Nutrition, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , CHINA
| | - Lilin Wang
- c Department of Cardiology, The First People's Hospital of Yunnan Provience , Kunming , CHINA
| | - Mingming Hu
- b Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , CHINA
| | - Lingling Xu
- b Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , CHINA
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10
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Quan H, Tan H, Li Q, Li J, Li S. Immunological hypoglycemia associated with insulin antibodies induced by exogenous insulin in 11 Chinese patients with diabetes. J Diabetes Res 2015; 2015:746271. [PMID: 25961056 PMCID: PMC4413037 DOI: 10.1155/2015/746271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate the characteristics of immunological hypoglycemia associated with insulin antibodies (IAbs) induced by exogenous insulin in Chinese patients with diabetes. METHODS The clinical data of patients with immunological hypoglycemia due to IAbs were retrospectively analyzed by screening patients with diabetes discharged from West China Hospital from 2007 to 2013. RESULTS A total of 11 patients (eight men and three women) were identified. Insulin-C-peptide separation was found in all patients via insulin and C-peptide release test. Previous insulin use was ceased after admission and was switched to oral hypoglycemic agents (OHAs) (8/11), lifestyle modification only (2/11), or regular human insulin (1/11). Hypoglycemia was ameliorated after a median of 20 days (interquartile range [IQR], 11-40), while IAbs turned negative after a median of 17 months (IQR, 4-19), and serum immunoreactive insulin (IRI) levels dropped substantially after a median of 22 months (IQR, 9-32) in these cases. CONCLUSIONS In insulin-treated patients with unexpected and refractory hypoglycemia even after insulin therapy was gradually reduced or even withdrawn, IAbs induced by exogenous insulin should be considered, and insulin withdrawal might be promptly needed. The course of immunological hypoglycemia was benign and self-limited.
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Affiliation(s)
- Heng Quan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
- *Jianwei Li: and
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
- *Sheyu Li:
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Kawanami D, Ito T, Watanabe Y, Kinoshita J, Sakamoto M, Isaka T, Utsunomiya K. Successful control of a case of severe insulin allergy with liraglutide. J Diabetes Investig 2012; 4:94-6. [PMID: 24843637 PMCID: PMC4019294 DOI: 10.1111/j.2040-1124.2012.00239.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 07/04/2012] [Accepted: 07/04/2012] [Indexed: 11/29/2022] Open
Abstract
A 72‐year‐old woman presented with repeated hypoglycemic and hyperglycemic episodes because of an insulin allergy. On admission, she was diagnosed with type B insulin resistance syndrome. She was also found to have anti‐insulin antibodies. After steroid therapy, glycemic control improved dramatically accompanied by the disappearance of the insulin allergy. We then introduced liraglutide, which successfully stabilized her glycemic episodes without allergic reactions. Liraglutide might be useful to treat patients with severe insulin allergy.
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Affiliation(s)
- Daiji Kawanami
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Tomoko Ito
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Yui Watanabe
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Jun Kinoshita
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Masaya Sakamoto
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Tsuyoshi Isaka
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Kazunori Utsunomiya
- Division of Diabetes, Metabolism and Endocrinology Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
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12
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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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Sahin SB, Cetinkalp S, Ozgen AG, Saygili F, Yilmaz C. The importance of anti-insulin antibody in patients with type 1 diabetes mellitus treated with continuous subcutaneous insulin infusion or multiple daily insulin injections therapy. Acta Diabetol 2010; 47:325-30. [PMID: 20842389 DOI: 10.1007/s00592-010-0221-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 08/31/2010] [Indexed: 11/25/2022]
Abstract
To investigate the influence of two insulin administration modalities, continuous subcutaneous insulin infusion (CSII) and multiple daily insulin injections (MDI) therapy with insulin analogues, on the development of insulin antibodies (IAs) in patients with type 1 diabetes mellitus and to assess the impact of IAs on glucose control and hypoglycaemia. 96 patients with type 1 diabetes mellitus treated with CSII (n = 48) or MDI (n = 48) were included in the study. Age, duration of diabetes, A1c, preprandial and postprandial blood glucose and hypoglycaemic events were compared between IA positive and negative patients. IA levels were higher in the CSII group (% 24.6 ± 14.2) than the MDI group (% 13.2 ± 9.9). Duration of diabetes and age were not associated with IA positiveness. While A1c, preprandial blood glucose and the frequency of hypoglycaemic events were similar in two groups, postprandial blood glucose was lower in IA positive group (P = 0.03). Patients with type 1 diabetes mellitus treated with CSII with insulin analogues had higher IA levels when compared to MDI therapy. However, the development of IAs did not impair the glycaemic control.
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Affiliation(s)
- S B Sahin
- Ege University Medical School, Izmir, Turkey.
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Hamatani H, Kobatake K, Yoshida H, Kobayashi S, Ueki K. [Prolonged hypoglycemia due to insulin auto-antibodies in a maintenance hemodialysis patient]. ACTA ACUST UNITED AC 2009; 98:1990-2. [PMID: 19764486 DOI: 10.2169/naika.98.1990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ishizuka T, Ogawa S, Mori T, Nako K, Nakamichi T, Oka Y, Ito S. Characteristics of the antibodies of two patients who developed daytime hyperglycemia and morning hypoglycemia because of insulin antibodies. Diabetes Res Clin Pract 2009; 84:e21-3. [PMID: 19328577 DOI: 10.1016/j.diabres.2009.02.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 12/27/2008] [Accepted: 02/09/2009] [Indexed: 11/30/2022]
Abstract
We encountered two patients who developed daytime hyperglycemia and early morning hypoglycemia because of insulin antibody (IA) that the affinity was extremely lower and the capacity extremely higher than those of IA in the insulin autoimmune syndrome, after their insulin treatment were changed from human insulin to analog insulin.
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Affiliation(s)
- Tsuneo Ishizuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai 980-8574, Japan
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16
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Fineberg SE, Kawabata TT, Finco-Kent D, Fountaine RJ, Finch GL, Krasner AS. Immunological responses to exogenous insulin. Endocr Rev 2007; 28:625-52. [PMID: 17785428 DOI: 10.1210/er.2007-0002] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Regardless of purity and origin, therapeutic insulins continue to be immunogenic in humans. However, severe immunological complications occur rarely, and less severe events affect a small minority of patients. Insulin autoantibodies (IAAs) may be detectable in insulin-naive individuals who have a high likelihood of developing type 1 diabetes or in patients who have had viral disorders, have been treated with various drugs, or have autoimmune disorders or paraneoplastic syndromes. This suggests that under certain circumstances, immune tolerance to insulin can be overcome. Factors that can lead to more or less susceptibility to humoral responses to exogenous insulin include the recipient's immune response genes, age, the presence of sufficient circulating autologous insulin, and the site of insulin delivery. Little proof exists, however, that the development of insulin antibodies (IAs) to exogenous insulin therapy affects integrated glucose control, insulin dose requirements, and incidence of hypoglycemia, or contributes to beta-cell failure or to long-term complications of diabetes. Studies in which pregnant women with diabetes were monitored for glycemic control argue against a connection between IAs and fetal risk. Although studies have shown increased levels of immune complexes in patients with diabetic microangiopathic complications, these immune complexes often do not contain insulin or IAs, and insulin administration does not contribute to their formation. The majority of studies have shown no relationship between IAs and diabetic angiopathic complications, including nephropathy, retinopathy, and neuropathy. With the advent of novel insulin formulations and delivery systems, such as insulin pumps and inhaled insulin, examination of these issues is increasingly relevant.
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Affiliation(s)
- S Edwin Fineberg
- Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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17
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Honda M, Kawashima Y, Kawamura H, Fujikawa H, Kikuchi K, Ohashi H, Mori Y, Miyakawa H, Ishibashi M. Acute liver dysfunction complicated with uncontrollable glycemia due to insulin antibody: successful treatment with glucocorticoid and lispro insulin. Intern Med 2006; 45:1225-9. [PMID: 17139123 DOI: 10.2169/internalmedicine.45.6009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Here, we report a case of acute liver dysfunction complicated with uncontrollable glycemia due to insulin antibody. The patient was admitted to our hospital due to diabetic ketoacidosis. He was administered insulin immediately, however, his fasting plasma glucose level remained unstable despite the insulin treatment. Blood biochemistry revealed severe liver dysfunction, although no markers including hepatitis virus or autoantibodies associated with autoimmune liver diseases were detected. The 125I-insulin binding rate was high (54%). The characteristics of insulin antibody in this patient were similar to the antibodies of IAS patients, therefore we administered oral glucocorticoid against insulin antibody. The reduction in the 125I-insulin binding rate and the binding capacity of the high affinity site of insulin antibodies were balanced after oral glucocorticoid therapy. In addition, preprandial subcutaneous regular insulin was switched to lispro insulin. Postprandial plasma glucose levels were relatively improved by lispro insulin. The etiology of acute liver dysfunction was unknown, however, we believe that the combination of oral glucocorticoid and lispro insulin was suitable and useful for preventing recurrent liver dysfunction in this patient.
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Affiliation(s)
- Munehiro Honda
- Fourth Department of Medicine, Teikyo University Shool of Medicine, Kawasaki
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18
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Koyama R, Nakanishi K, Kato M, Yamashita S, Kuwahara H, Katori H. Hypoglycemia and Hyperglycemia Due to Insulin Antibodies against Therapeutic Human Insulin: Treatment with Double Filtration Plasmapheresis and Prednisolone. Am J Med Sci 2005; 329:259-64. [PMID: 15894868 DOI: 10.1097/00000441-200505000-00007] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Two diabetic patients, who had been treated with human insulin, suffered from fasting hypoglycemia and postprandial hyperglycemia. The insulin-binding capacities of their sera were high, and a large amount of total insulin and prolonged presence of free insulin in the sera were shown. Scatchard analysis of these insulin antibodies revealed that high-affinity insulin antibodies had larger capacity and stronger affinity compared with commonly insulin-treated patients. Treatment with double filtration plasmapheresis and subsequent administration of prednisolone in the second patient reduced such antibodies and resulted in recovery of glycemic control by insulin. Hypoglycemia and hyperglycemia could be incurred when insulin antibodies with strong affinity and high capacity in high-affinity sites arise. This condition can be treated with double filtration plasmapheresis and subsequent administration of prednisolone.
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Affiliation(s)
- Rikako Koyama
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
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Abstract
Autoimmune hypoglycemia is a rare but fascinating syndrome of hypoglycemia caused by the interaction of endogenous antibodies with insulin or the insulin receptor. Awareness of autoimmune hypoglycemia is important because the syndrome may produce severe neuroglycopenic symptoms and may be confused with the presence of an insulinoma. A correct diagnosis is important to avoid unnecessary surgical intervention in patients who are best treated with conservative support, watchful waiting, or in some cases, immunosuppressive therapy.
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Affiliation(s)
- J B Redmon
- Department of Medicine, University of Minnesota Medical School, Minneapolis, USA.
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