A case of type 1 diabetes mellitus with which localized insulin allergy was markedly alleviated by switching to insulin glulisine
Acta Diabetol
A case of type 1 diabetes mellitus with which localized insulin allergy was markedly alleviated by switching to insulin glulisine
Kahori Watanabe 0 1 2
Yoshiki Kusunoki 0 1 2
Tomoyuki Katsuno 0 1 2
Rie Nakae 0 1 2
Toshihiro Matsuo 0 1 2
Fumihiro Ochi 0 1 2
Masaru Tokuda 0 1 2
Takafumi Akagami 0 1 2
Masayuki Miuchi 0 1 2
Jun-ichiro Miyagawa 0 1 2
Mitsuyoshi Namba 0 1 2
0 Division of Innovative Diabetes Treatment, Department of Internal Medicine, Hyogo College of Medicine , 1-1, Mukogawa-cho, Nishinomiya, Hyogo 663-8501 , Japan
1 Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Hyogo College of Medicine , 1-1, Mukogawa-cho, Nishinomiya, Hyogo 663-8501 , Japan
2 & Yoshiki Kusunoki
Managed by Massimo Porta.
Insulin glulisine; Insulin allergy; Skin allergological test; Continuous subcutaneous insulin infusion
Introduction
There have been numerous reports of allergies with causes
such as differences in the amino acid sequences between
human insulin and insulin extracted from porcine and
bovine pancreas. Insulin allergy leads to deterioration of
blood glucose control and decrease in quality of life.
However, the availability of genetically recombinant
human insulin formulations has led to insulin allergy
becoming uncommon [
1
], and such allergies also occur
much more rarely when insulin analog formulations are
administered.
The present report is about a patient who showed
allergic reactions to various insulin formulations, but
showed only a weak allergic reaction to insulin glulisine,
so the symptoms of insulin allergy ceased when treatment
was switched to insulin glulisine.
The patient was a 28-year-old female with type 1 diabetes
mellitus. In February 2011, she developed the subjective
symptoms of oral dryness, polydipsia, and polyuria,
although she did not consult a physician. In March 2011,
her mother found her unconsciousness in her home, and she
was taken as an emergency to a different hospital, where
diabetic ketoacidosis and type 1 diabetes mellitus were
diagnosed. Intensive insulin therapy was then initiated,
using insulin aspart and insulin detemir. However, because
of the instability of fluctuations in blood glucose level, the
attending physician at that hospital recommended initiation
of continuous subcutaneous insulin infusion (CSII), the
patient was therefore referred to our hospital in April 2011,
and CSII was initiated. She then continued to visit our
hospital as an outpatient, and the hemoglobin A1c (HbA1c)
level was maintained at approximately 6.5 % (48
mmol/mol) by means of CSII using insulin lispro.
The patient had told only a few close friends about
having type 1 diabetes mellitus, so, when she travelled with
other friends, and work colleagues, she chose to control her
blood glucose by multiple daily injections rather than CSII.
In addition, she had expressed strong interest in different
insulin formulations, and various formulations, including
insulin glulisine, had therefore been tried. As basal insulin,
she had a history of use of insulin detemir and insulin
glargine. She had not previously had particular problems
with any of these formulations.
Since June 2015, the patient has developed the
subjective symptoms of redness, swelling, and itchiness around
the CSII cannula insertion site, and she was examined at
our hospital in July. At that time, her blood glucose level
was controlled by CSII with insulin lispro. At the time of
examination, the casual blood glucose level was 157 mg/
dL, the HbA1c level was 6.3 % (45 mmol/mol), and the
body mass index was 21.8 kg/m2. Examination showed
erythema and induration at the cannula insertion site, so
localized insulin allergy was suspected (Fig. 1a).
Therefore, the IgE antibody specific to human insulin was
measured, the concentration was found to be 2.32 UA/mL
(normal range B 0.34 UA/mL), and the condition was
judged to be class 2 (positive). The concentration of
nonspecific IgE antibodies, on the other hand, was 21.8 IU/mL
with no elevation (normal range B 173 IU/mL), and no
eosinophilia was found (white blood cell count: 6410 cells/
lL; eosinophil percentage of white blood cell count:
0.6 %).
Next, intradermal tests were carried using various
insulin formulations. Each insulin formulation was diluted
to 0.05 units per 0.05 mL with physiological saline
solution, and 0.02 mL of the resulting solution was injected
intradermally, followed by evaluation. The findings were
that mild erythema measuring 5 9 5 mm developed
15 min after intradermal injection of insulin glulisine,
whereas with other insulin formulations redness developed
immediately after intradermal injection, and erythema at
least 10 mm in diameter and induration at least 5 mm in
diameter developed after 15 min (Table 1). All rashes
cleared up within 24 h after the intradermal test.
On the basis of the above findings, localized insulin
allergy was suspected; so the cannula insertion site was
changed, and a basal insulin rate of (...truncated)