Continuous subcutaneous insulin infusion allows tolerance induction and diabetes treatment in a type 1 diabetic child with insulin allergy

Use of continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes mellitus: a systematic mapping review

BACKGROUND

Among the treatments for type 1 diabetes mellitus (T1DM), Continuous Subcutaneous Insulin Infusion (CSII) is a device that infuses insulin through the subcutaneous tissue in an uninterrupted manner and that comes closest to the physiological secretion of insulin. The use of CSII can provide the family with greater security and children and adolescents have more autonomy in relation to the treatment of T1DM. There is a lack of reviews that systematically gather the mounting evidence about the use of CSII in children and adolescents with T1DM. Therefore, the aim of this review was to group and describe primary and secondary studies on the use of CSII in children and adolescents with T1DM.

METHODS

A systematic mapping review was performed based on searches in the following databases: PubMed, Embase, CINAHL, Lilacs and PsycINFO, using a combination of descriptors and keywords. The screening of the studies was carried out with the aid of the Rayyan software and reading in full was conducted independently by two reviewers. The data extraction of the studies was performed using an extraction tool adapted and validated by researchers specialized in diabetes. The data were analyzed according to the content analysis technique. The map from geocoding of the studies was produced using the ArcGis 10.5 software.

RESULTS

A total of 113 studies were included in the review, including primary studies, literature reviews and gray literature publications. The content analysis of the results of the studies allowed for the identification of four categories: 1) metabolic control; 2) support networks; 3) benefits of using CSII; and 4) challenges of using CSII, each category having its respective subcategories. The review also made it possible to conduct a rigorous mapping of the literature on the use of CSII considering the location of development and the design of the studies.

CONCLUSIONS

The use of CSII should be indicated by health professionals able to prepare children, adolescents, and their families for the treatment of T1DM, and, despite being a technological device, it may not be suitable for the entire pediatric population.

The complexities of insulin allergy: a case and approach

Background

Insulin hypersensitivity is rare, but challenging for individuals with diabetes. The prevalence of insulin allergy has decreased since the introduction of human recombinant insulin preparations. Hypersensitivity reactions range from injection site erythema and swelling, to anaphylaxis. While some reactions are to excipients (zinc, protamine, metacresol), many are to recombinant insulin itself. We present a case of type 1 hypersensitivity to various preparations of insulin in a patient with insulin-dependent type 2 diabetes mellitus (T2DM).

Case presentation

A 61-year-old woman with a 30-year history of insulin-dependent T2DM was referred for evaluation of reactions to insulin. She had two episodes over 5-months; both required Emergency Department visits and epinephrine administration. The first episode entailed a burning sensation of the extremities and nausea, immediately after injecting NovoRapid^® insulin. The second event entailed a similar reaction but this time there was also angioedema of the upper airway with difficulty breathing and hypotension, immediately after injecting Levemir^® and NovoRapid^®, and taking metformin. There were no cofactors such as exercise, infectious illness, or NSAIDs use. Skin testing was performed with metformin, Lantus^®, Humalog^®, NovoRapid^®, glulisine, insulin regular, NPH, Levemir^® and the excipient protamine, as per published testing concentrations. Metacresol was not tested as its use was restricted by the hospital pharmacy. Insulin preparations with and without metacresol were included in testing however. A clinic staff served as a negative control. The patent had negative testing with protamine, but sensitization to all insulin preparations. Metformin skin testing and challenge along with latex IgE were negative. Subsequently, she underwent intentional weight loss of 70 lb, and was started on oral hypoglycemics with good effect.

Conclusions

Our case highlights the importance of diagnosing insulin allergy through a detailed history and focused testing. Therapeutic strategies include avoidance and insulin alternatives, alternate insulin preparations, or desensitization. In severe recurrent hypersensitivity reactions, Omalizumab or pancreatic transplantation have been effective.

Exogenous recombinant human insulin-induced severe hypersensitivity reaction precipitating hyperglycemic crisis: A clinical conundrum

Hypersensitivity reactions against exogenous insulin are a rare clinical entity after the advent of recombinant human insulin; however, there are still case reports wherein patients develop hypersensitivity reactions against insulin. We present the case of a type 1 diabetes mellitus patient who developed type 1 hypersensitivity reaction against subcutaneous insulin. He had recurrent episodes of diabetic ketoacidosis after developing hypersensitivity reactions against insulin, requiring multiple hospital admissions. When he presented to us, he was on both insulin infusion and subcutaneous insulin, requiring a daily insulin dose of about 800 units and having severe insulin hypersensitivity reactions and hyperglycemia. He had multiple subcutaneous erythematous nodules at the insulin injection sites, however, had no evidence of systemic allergy. Investigations revealed eosinophilic leukocytosis, and high IgE levels and skin biopsy showing evidence of insulin hypersensitivity. He was desensitized to insulin according to Heinzerling et al. insulin desensitization protocol and subsequently with immunomodulation therapy using steroids (pulse methylprednisolone) and mycophenolate mofetil as well as by installation of insulin pump.

RAPID DESENSITIZATION WITH INTRAVENOUS INSULIN IN A PATIENT WITH DIABETIC KETOACIDOSIS AND INSULIN ALLERGY

OBJECTIVE

We report a case of insulin desensitization in a patient with known allergy to multiple insulin preparations who presented with diabetic ketoacidosis (DKA).

METHODS

Clinical and laboratory data, and desensitization protocols are presented.

RESULTS

A 65-year-old woman with type 2 diabetes and a documented insulin allergy presented with severe DKA. She was managed initially with intravenous (IV) fluids, sodium bicarbonate, and hemodialysis. An intradermal skin test was positive for 0.01 units/mL of human regular insulin. A rapid desensitization protocol for IV human regular insulin was initiated after pretreatment with methylprednisolone, ranitidine, montelukast, and cetirizine. An initial dilution of 1 unit of insulin in 100,000 mL of 0.9% sodium chloride was started at 5 mL/hour IV. The dilution was increased at 60-minute intervals to 1 unit/10,000 mL, 1 unit/1,000 mL, 1 unit/100 mL, 1 unit/10 mL, then 1 unit/1 mL. The dose was then increased from 1 to 7 units/hour (0.1 units/kg body weight/hour). The anion gap closed after 24 hours, and overlapping desensitization was started for subcutaneous (SC) human regular insulin starting with 0.00001 units with a gradual increase to 7 units before meals and 6 units at bedtime over 5 days. There were no anaphylactic reactions to IV or SC insulin. She was discharged with human regular insulin SC 4 times daily, oral montelukast, cetirizine, diphenhydramine as needed, and an epinephrine pen. No allergic reactions were reported at follow-up visits.

CONCLUSION

Rapid insulin desensitization is possible to allow treatment of DKA with human regular insulin IV in patients with known insulin allergy.

Hypersensitivity reactions to human insulin analogs in insulin-naïve patients: a systematic review

OBJECTIVE

The objective of this study was to raise awareness of hypersensitivity reactions to human insulin analogs (HIAs) in insulin-naïve patients and encourage consistent and detailed reporting of HIA reactions.

DATA SOURCES

A search of PubMed, MEDLINE and International Pharmaceutical Abstracts using the terms 'insulin' and 'hypersensitivity' was completed with English language, humans, and publication date after 1 January 1990 as limits.

STUDY SELECTION AND DATA EXTRACTION

The initial search identified 598 articles. These titles and abstracts were reviewed for relevance (e.g. mention of HIA) resulting in the exclusion of 477 articles. The full texts of the remaining titles were evaluated in addition to each article's references to identify additional reports meeting criteria (n = 14). Upon extensive review, 118 articles were excluded for not meeting prespecified inclusion criteria, resulting in 17 articles.

DATA SYNTHESIS

Evidence supporting hypersensitivity reactions to HIAs was variable, potentially due to a variety of causes (e.g. difficulty identifying a true case of hypersensitivity reaction to HIAs). Inconsistencies were noted for the identification, confirmatory testing, management, and reporting of these reactions. Management strategies included use of insulin desensitization protocols, antihistamines, steroids, immunosuppressant/immunomodulator therapies, conversion to noninsulin therapies, and pancreas transplantation.

CONCLUSIONS

Complete and consistent identification, evaluation, management, and reporting of these reactions is essential. Specific aspects of the patient's history should be reported, including previous insulin exposure, the specific HIAs used, duration of use prior to the reaction, a clear timeline of the reaction, and discussion of precipitating events or confounding factors.

20 Years of insulin lispro in pediatric type 1 diabetes: a review of available evidence

BACKGROUND

Insulin lispro, the first rapid-acting insulin analog, was developed 20 years ago and has been studied in multiple situations and various populations.

OBJECTIVE

To review the literature on the use of insulin lispro in children, adolescents, and young adults.

PATIENTS

Children, adolescents, and young adults with type-1-diabetes.

METHODS

One hundred and twenty-two relevant publications, identified by a systematic (MEDLINE) and manual literature search, were reviewed.

RESULTS

Multiple daily injection (MDI) treatment with insulin lispro or other rapid-acting insulins, mainly using neutral protamine Hagedorn (NPH) insulin as the basal component, was associated with reduced postprandial glucose excursions, similar or improved HbA1c levels, and similar or reduced risks of severe hypoglycemia when compared with regular human insulin across all age-groups. Continuous subcutaneous insulin infusion (CSII)-treatment with insulin lispro also showed similar or improved glycemic control vs. MDI- or other CSII-regimens across all age-groups, without increasing the rate of severe hypoglycemia. The other two more recently developed rapid-acting insulins (aspart, glulisine) demonstrated non-inferiority to lispro on HbA1c. Long-term observational studies and real-life experience indicate that the increasing use of optimized MDI- and CSII-regimens with insulin lispro was associated with improvements in overall glycemic control.

CONCLUSIONS

For almost 20 years, rapid-acting insulins, in particular insulin lispro as the first-in-class, have contributed to broadening the treatment options for the unique needs of pediatric patients with type-1-diabetes across all age-groups, and have enabled more physiological insulin administration. Now widely used, they have allowed pediatric patients to safely reach better glycemic control, with more flexibility in their daily lives.

Insulin Allergy

Objective: A case of insulin allergy to insulin aspart, insulin aspart protamine/insulin aspart 70/30, insulin lispro, and insulin lispro protamine/insulin lispro 75/25 in a patient with type 2 diabetes mellitus is reported. Case Summary: A 76-year-old Caucasian male weighing 81 kg presented with complaints of burning, lumps, and a rash where his insulin aspart protamine/insulin aspart 70/30 was injected 2 months after initiation. Because poor injection technique can mimic insulin allergy, the patient was counseled again on proper injection technique. The patient presented 2 weeks later with the same complaints. Insulin aspart protamine/insulin aspart 70/30 was discontinued and insulin lispro protamine/insulin lispro 75/25 was initiated. The patient presented 3 months later with a localized reaction. Insulin lispro protamine/insulin lispro 75/25 was discontinued and insulin U100 glargine and insulin lispro were initiated. One week later, the patient still had complaints of a localized reaction and was referred to an allergist for testing. Skin prick tests revealed insulin allergy to insulin aspart and insulin lispro but not to insulin U100 glargine or insulin glulisine. The patient’s regimen was changed to insulin U100 glargine and insulin glulisine, and he has not experienced any reaction since. Discussion: Allergic reactions to human insulin preparations are rare and may present as a localized reaction or a generalized reaction. Different types of allergic reactions to human insulin have been reported, including type I, type III, and type IV hypersensitivity reactions. If insulin allergy is suspected, the following steps should be taken to confirm such allergy: evaluation of injection technique, switching to a different insulin preparation, and referral to an allergist for allergy testing if necessary. Conclusion: A patient with type 2 diabetes mellitus experienced a type I hypersensitivity reaction to insulin aspart, insulin aspart protamine/insulin aspart 70/30, insulin lispro, and insulin lispro protamine/insulin lispro 75/25.

Hypersensitivity Reaction to Insulin Glargine and Insulin Detemir in a Pediatric Patient: A Case Report

Allergy to human insulin or its analogs is rare, but it is still a significant issue in current diabetes care. Allergic reactions can range from localized injection site reactions to generalized anaphylaxis, and they can be caused by excipients or the insulin molecules themselves. We presented a case of a 14-year-old male patient with generalized allergic reactions to insulin glargine and insulin detemir. The patient was successfully managed by being switched to a continuous subcutaneous insulin infusion with insulin aspart. Allergic reactions to insulin detemir and insulin glargine have both been well described, with insulin detemir allergy appearing to be more common. There are several potential mechanisms for insulin allergy, and immunologic characteristics vary among different insulin analogs. After confirming insulin allergy in practice, management involves treating symptoms and switching insulin preparations. This is the first documented case of allergies to both insulin glargine and insulin detemir in a pediatric patient. Exact mechanism of insulin allergy is unknown, and management strategies must be individualized for each patient.

Successful management of insulin allergy and autoimmune polyendocrine syndrome type 4 with desensitization therapy and glucocorticoid treatment: a case report and review of the literature

Introduction. Insulin allergy is a rare complication of insulin therapy, especially in type 1 diabetes mellitus (T1DM). Key manifestations are hypersensitivity-related symptoms and poor metabolic control. T1DM, as well as insulin allergy, may develop in the context of autoimmune polyendocrine syndrome (APS), further complicating management. Case Report. A 17-year-old male patient, diagnosed with T1DM, was treated with various insulin therapy schemes over several months, which resulted in recurrent anaphylactoid reactions and poor glycemic control, after which he was referred to our Endocrinology and Immunology Department. A prick test was carried out for all commercially available insulin presentations and another insulin scheme was designed but proved unsuccessful. A desensitization protocol was started with Glargine alongside administration of Prednisone, which successfully induced tolerance. Observation of skin lesions typical of vitiligo prompted laboratory workup for other autoimmune disorders, which returned positive for autoimmune gastritis/pernicious anemia. These findings are compatible with APS type 4. Discussion. To our knowledge, this is the first documented case of insulin allergy in type 4 APS, as well as this particular combination in APS. Etiopathogenic components shared by insulin allergy and APS beg for further research in immunogenetics to further comprehend pathophysiologic aspects of these diseases.