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Obata Y, Takayama K, Nishikubo H, Tobimatsu A, Matsuda I, Uehara Y, Maruo Y, Sho H, Kosugi M, Yasuda T. Exogenous insulin antibody syndrome in a patient with diabetes secondary to total pancreatectomy. Diabetol Int 2023; 14:211-216. [PMID: 37090132 PMCID: PMC10113417 DOI: 10.1007/s13340-022-00611-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/24/2022] [Indexed: 12/25/2022]
Abstract
Exogenous insulin can induce insulin antibodies that have a low affinity/high binding capacity. Similar to what is observed in insulin autoimmune syndrome, these insulin antibodies can cause fasting hypoglycemia and postprandial hyperglycemia, a phenomenon known as "exogenous insulin antibody syndrome" (EIAS). Cases of EIAS in patients with type 1 and type 2 diabetes have been sporadically reported, mainly in Asia. However, there has been no report on EIAS in patients with diabetes secondary to total pancreatectomy treated with insulin analogs. A 74-year-old man with diabetes after total pancreatectomy had been treated with continuous subcutaneous insulin infusion using an insulin analog, lispro, and developed recurrent early morning hypoglycemia even after discontinuation of nocturnal basal insulin. His fasting serum lispro level was high even approximately 9 h after the last lispro dose. He had a high titer (72.7%) of insulin antibodies, and a Scatchard analysis revealed low affinity/high binding capacity. These findings suggested that the patient's recurrent early morning hypoglycemia was associated with insulin antibodies against lispro, and we, therefore, switched from lispro to another insulin analog, glulisine. His hypoglycemia improved, accompanied by a dramatic decrease in his insulin antibodies and serum glulisine levels. Early morning hypoglycemia in patients with diabetes secondary to total pancreatectomy may often be explained by high glycemic variability, malnutrition, and/or glucagon deficiency. However, in cases of recurrent early morning hypoglycemia, EIAS should be considered as a potential differential diagnosis.
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Affiliation(s)
- Yoshinari Obata
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Kana Takayama
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Hideyuki Nishikubo
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Aoki Tobimatsu
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Izumi Matsuda
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Yuhei Uehara
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Yumiko Maruo
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Hiroyuki Sho
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Motohiro Kosugi
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
| | - Tetsuyuki Yasuda
- Department of Diabetes and Endocrinology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennojiku, Osaka 543-0035 Japan
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Kawamura R, Miyao S, Onuma H, Uchigata Y, Kawasaki E, Ohashi J, Shiraishi S, Nishida W, Yokomoto-Umakoshi M, Takata Y, Osawa H, Makino H. Recurrent Hypoglycemia Due to a High Titer of Insulin Antibody in Response to Exogenous Insulin Administration in Two Cases of Type 1 Diabetes. Intern Med 2022; 61:687-695. [PMID: 34471020 PMCID: PMC8943391 DOI: 10.2169/internalmedicine.7647-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In the first case, a 60-year-old man who was using continuous subcutaneous insulin infusion (CSII), developed recurrent hypoglycemia due to insulin antibodies. This is the first report of such a case using CSII. In the second case, a 70-year-old man was follow-up case who developed hypoglycemia while using human insulin. In both cases, the hypoglycemia subsided after switching to multiple daily insulin injection and/or insulin preparation. The results of Scatchard analyses of the two cases were similar to those of cases of insulin autoimmune syndrome (IAS) that improved after recovery from hypoglycemia.The clinical characteristics and Scatchard analysis data were essentially the same as those for IAS, except for the presence of insulin administration.
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Affiliation(s)
- Ryoichi Kawamura
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | | | - Hiroshi Onuma
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
- Department of Diabetes, Endocrine and Metabolic Disease, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | | | - Eiji Kawasaki
- Department of Diabetes and Endocrinology, Shin-Koga Hospital, Japan
| | - Jun Ohashi
- Department of Biological Sciences, Graduate School of Science, The University of Tokyo, Japan
| | | | - Wataru Nishida
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Maki Yokomoto-Umakoshi
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Yasunori Takata
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Hideichi Makino
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
- Shiraishi Hospital Diabetes Center, Japan
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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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Komiya T, Mori A, Nishii N, Oda H, Onozawa E, Seki S, Sako T. Relationship between anti-insulin antibody production and severe insulin resistance in a diabetic cat. J Vet Med Sci 2021; 83:661-665. [PMID: 33840723 PMCID: PMC8111345 DOI: 10.1292/jvms.20-0345] [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] [Indexed: 11/22/2022] Open
Abstract
A 5-year-old castrated male domestic shorthair cat was diagnosed with diabetic
ketoacidosis and severe insulin resistance. Although the conventional treatment for
diabetic ketoacidosis was provided, the cat required frequent hospitalization because of
severe dehydration and repeated diabetic ketoacidosis. We detected anti-insulin antibodies
for human in this cat. Serum insulin-binding IgG levels were markedly elevated compared
with those in healthy cats and other diabetic cats. We initiated prednisolone to suppress
the effects of anti-insulin antibodies. After initiation of prednisolone, the cat was
gradually recovered with increasing activity and appetite. Furthermore, satisfactory
glycemic control was achieved with combined subcutaneous injection of insulin detemir and
insulin degludec.
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Affiliation(s)
- Takumi Komiya
- School of Veterinary Nursing & Technology, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino, Tokyo 180-8602, Japan.,Animal Emergency Center Fuchu, 1-17-1 Midoricho, Fuchu, Tokyo 183-0006, Japan
| | - Akihiro Mori
- School of Veterinary Nursing & Technology, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino, Tokyo 180-8602, Japan
| | - Naohito Nishii
- Joint Department of Veterinary Medicine, Faculty of Applied Biological Sciences, Gifu University, 1-1 Yanagido, Gifu 501-1193, Japan
| | - Hitomi Oda
- School of Veterinary Nursing & Technology, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino, Tokyo 180-8602, Japan
| | - Eri Onozawa
- School of Veterinary Nursing & Technology, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino, Tokyo 180-8602, Japan
| | - Seri Seki
- School of Veterinary Nursing & Technology, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino, Tokyo 180-8602, Japan
| | - Toshinori Sako
- School of Veterinary Nursing & Technology, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino, Tokyo 180-8602, Japan
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Xiao Y, Li X, Chao C, Huang G, Tang W, Liu S, Xie Z, Zhou Z. Severe insulin resistance due to insulin antibodies. J Diabetes 2018; 10:611-613. [PMID: 29493088 DOI: 10.1111/1753-0407.12657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 02/24/2018] [Accepted: 02/26/2018] [Indexed: 01/05/2023] Open
Affiliation(s)
- Yang Xiao
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Xia Li
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Chen Chao
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Gan Huang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Weili Tang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Shiping Liu
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Zhiguo Xie
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, 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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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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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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9
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Yoshida M, Asai M, Miyata M, Ogawa K, Maeda H, Oiso Y. Combination therapy with liraglutide and sulfonylurea for a type 2 diabetic patient with high titer of anti-insulin antibodies produced by insulin therapy. Diabetes Res Clin Pract 2012; 96:e55-6. [PMID: 22257418 DOI: 10.1016/j.diabres.2011.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 12/15/2011] [Indexed: 10/14/2022]
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10
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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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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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