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Paz-Ibarra J, Concepción-Zavaleta M, Quiroz-Aldave JE, Kcomt Lam M, Gilvonio Huauya E, Sueldo Espinoza D, Gago Cajacuri G. A rare case of autoimmune dysglycemia syndrome associated with systemic lupus erythematosus and dermatomyositis. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023; 20:em512. [DOI: 10.29333/ejgm/13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Autoimmune dysglycemia syndrome (ADS) is a rare condition that presents as episodes of hypoglycemia as well as hyperglycemia and is classified as insulin autoimmune syndrome (IAS) and type B insulin resistance (TBIR). Autoimmunity plays a key role in the pathogenesis of this disorder, as evidenced by the presence of autoantibodies against endogenous insulin or the insulin receptor, and by its association with rheumatologic disorders. Treatment usually includes glycemic control and immunomodulatory agents. We report a case of a 31-year-old woman who was admitted for severe hypoglycemia. Further workup revealed underlying systemic lupus erythematosus (SLE) with renal involvement. During hospitalization, she continued to experience episodes of fasting hypoglycemia, as well as episodes of postprandial hyperglycemia. Hypoglycemia associated with a high serum insulin concentration and positive anti-insulin antibodies were consistent with IAS. Likewise, hyperglycemia and hypoglycemia in association with weight loss, acanthosis nigricans, polycystic ovarian syndrome, and normotriglyceridemia strongly suggested TBIR, although testing for antibodies against the insulin receptor was not available in Peru. Immunosuppressive therapy and metformin were indicated, resulting in remission of SLE and ADS. Years later, the patient exhibited features of dermatomyositis, such as Raynaud’s phenomenon, muscular weakness, heliotrope exanthema, and elevated muscle enzymes. Once again, the patient received immunosuppressive therapy. ADS is an infrequent cause of hypoglycemia, and the coexistence of its two pathophysiological mechanisms in a patient with SLE and subsequent development of dermatomyositis is even more rare. Our case is the first one reported describing this association.
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Affiliation(s)
- José Paz-Ibarra
- Division of Endocrinology, Hospital Nacional Edgardo Rebagliati Martins, Universidad Nacional Mayor de San Marcos, Lima, PERU
| | | | | | - Mikaela Kcomt Lam
- Department of Medicine, Universidad Privada Antenor Orrego, Trujillo, PERU
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Paz-Ibarra J, Concepción-Zavaleta M, Quiroz-Aldave JE, Kcomt Lam M, Gilvonio Huauya E, Sueldo Espinoza D, Gago Cajacuri G. A rare case of autoimmune dysglycemia syndrome associated with systemic lupus erythematosus and dermatomyositis. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023; 20:em512. [DOI: https:/doi.org/10.29333/ejgm/13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Autoimmune dysglycemia syndrome (ADS) is a rare condition that presents as episodes of hypoglycemia as well as hyperglycemia and is classified as insulin autoimmune syndrome (IAS) and type B insulin resistance (TBIR). Autoimmunity plays a key role in the pathogenesis of this disorder, as evidenced by the presence of autoantibodies against endogenous insulin or the insulin receptor, and by its association with rheumatologic disorders. Treatment usually includes glycemic control and immunomodulatory agents. We report a case of a 31-year-old woman who was admitted for severe hypoglycemia. Further workup revealed underlying systemic lupus erythematosus (SLE) with renal involvement. During hospitalization, she continued to experience episodes of fasting hypoglycemia, as well as episodes of postprandial hyperglycemia. Hypoglycemia associated with a high serum insulin concentration and positive anti-insulin antibodies were consistent with IAS. Likewise, hyperglycemia and hypoglycemia in association with weight loss, acanthosis nigricans, polycystic ovarian syndrome, and normotriglyceridemia strongly suggested TBIR, although testing for antibodies against the insulin receptor was not available in Peru. Immunosuppressive therapy and metformin were indicated, resulting in remission of SLE and ADS. Years later, the patient exhibited features of dermatomyositis, such as Raynaud’s phenomenon, muscular weakness, heliotrope exanthema, and elevated muscle enzymes. Once again, the patient received immunosuppressive therapy. ADS is an infrequent cause of hypoglycemia, and the coexistence of its two pathophysiological mechanisms in a patient with SLE and subsequent development of dermatomyositis is even more rare. Our case is the first one reported describing this association.
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Affiliation(s)
- José Paz-Ibarra
- Division of Endocrinology, Hospital Nacional Edgardo Rebagliati Martins, Universidad Nacional Mayor de San Marcos, Lima, PERU
| | | | | | - Mikaela Kcomt Lam
- Department of Medicine, Universidad Privada Antenor Orrego, Trujillo, PERU
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Late Systemic Lupus Erythematosus-Associated Insulin Resistance Syndrome: A Rare Cause of De Novo Diabetes Mellitus. Case Rep Med 2022; 2022:4655804. [PMID: 36275943 PMCID: PMC9586807 DOI: 10.1155/2022/4655804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022] Open
Abstract
The association of type B insulin resistance syndrome (TBIRS) due to autoimmune diseases such as systemic lupus erythematosus (SLE) is uncommon. This is partly due to the lack of established criteria for the diagnosis of this resistance. However, some clinical aspects may suggest that the diagnosis does not necessarily have to be positive insulin receptor antibodies as such patients could respond to immunosuppressive treatment. Methods. We describe a case and have performed a literature review on PubMed/MEDLINE, EMBASE, and Google Scholar bibliographic databases to identify all case reports. All available studies from January 1975 through December 2020 were included. Data collected were tabulated, and outcomes were analyzed cumulatively. Results. Thirty-one cases of TBIRS associated with SLE have been described. These patients presented with catabolic symptoms and hyperglycemia in most cases, with an average time from the onset of symptoms of four months. In addition to that clinical characteristics related to SLE were variable, along with certain common characteristics such as acanthosis in 60% of patients. Almost all the patients had antibodies against insulin receptors. The insulin doses required by the patients ranged from 450 to 25,000 U daily. Remission was achieved in 80% of the patients with a two-year follow-up. Most patients associated with late-onset SLE, like our patient, achieved metabolic control after immunosuppressive treatment. Conclusion. High insulin resistance in patients with de novo diabetes mellitus (DM) without obesity should be considered as a possible clinical manifestation of an autoimmune disease such as SLE, with a good metabolic response to the immunosuppressive management established.
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Oest L, Roden M, Müssig K. Comparison of patient characteristics between East Asian and non-East Asian patients with insulin autoimmune syndrome. Clin Endocrinol (Oxf) 2022; 96:328-338. [PMID: 34778997 DOI: 10.1111/cen.14634] [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: 06/25/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Insulin autoimmune syndrome (IAS) is the third most common cause of spontaneous hypoglycaemia in Japan but very rare in the rest of the world. We aimed to identify factors, which are associated with the occurrence of IAS and which may differ between East Asian and non-East Asian patients. DESIGN A PubMed search using the search terms 'insulin autoimmune syndrome' and 'Hirata disease' revealed a total of 287 reports of IAS cases, including one previously unpublished own case. RESULTS Mean age (±standard deviation) was 52 ± 19 years in East Asian and 54 ± 21 years in non-East Asian patients (p > .05). In both groups, there were more females. Mean body mass index was lower in East Asian than in non-East Asian patients (23.0 ± 4.3 vs. 27.1 ± 5.6 kg/m2 , p < .0001). Postprandial hypoglycaemia was more common in non-East Asian patients (p < .05). East Asian patients took more frequently antithyroid medications and non-East Asian patients angiotensin-converting enzyme (ACE) inhibitors (both p < .0001). Graves' disease and other autoimmune diseases were more frequently observed in East Asian patients (both p < .01). Parameters of glucose metabolism were comparable in both groups, independent of diabetes diagnosis (p > .05), except for insulin that was higher in East Asian compared to non-East Asian metabolically healthy patients (p < .01). Human leukocyte antigen (HLA)-DRB1*0406 was the most frequent HLA-type in East Asian patients (p < .0001), whereas DRB1*0403 and *0404 were more frequent in non-East Asian patients (both p < .05). Non-East Asian patients received more secondary treatments, including plasmapheresis and rituximab, whereas medication discontinuation was more common in East Asian patients (all p < .05). Outcome was similar in both groups (p > .05). CONCLUSIONS Factors associated with IAS markedly differ between East Asian and non-East Asian patients, with autoimmune disorders, particularly Graves' disease, antithyroid medications, and HLA-DRB1*0406 more prevalent in East Asian patients and cardiovascular and plasma cell diseases, ACE inhibitors and HLA-DRB1*0403 more prevalent in non-East Asian patients.
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Affiliation(s)
- Lisa Oest
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
| | - Karsten Müssig
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
- Department of Internal Medicine and Gastroenterology, Niels Stensen Hospitals, Franziskus Hospital Harderberg, Georgsmarienhütte, Germany
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Petersen MC, Graves JM, Yao T, Schomburg L, Minich WB, Parks DL, McGill JB, Salam M. Insulin Receptor Autoantibody-mediated Hypoglycemia in a Woman With Mixed Connective Tissue Disease. J Endocr Soc 2022; 6:bvab182. [PMID: 34913021 PMCID: PMC8668203 DOI: 10.1210/jendso/bvab182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
Autoantibodies to the insulin receptor are rare and typically cause severe insulin resistance and hyperglycemia, a condition termed type B insulin resistance. Uncommonly, antibodies to the insulin receptor can cause hypoglycemia. We present the case of a woman who developed recurrent severe hypoglycemia and myopathy, was found to have insulin receptor autoantibodies and mixed connective tissue disease, and had resolution of hypoglycemia with immunosuppression. A 55-year-old woman with a history of obesity, hypertension, and prior hemorrhagic stroke presented with recurrent severe hypoglycemia. A diagnostic fast resulted in hypoinsulinemic hypoketotic hypoglycemia. Adrenal function was intact. Progressive myopathy had developed simultaneously with her hypoglycemia, and rheumatologic evaluation revealed mixed connective tissue disease. The plasma acylcarnitine profile was normal, extensive oncologic evaluation including insulin-like growth factor 2 measurement was unrevealing, and anti-insulin antibody testing was negative. Ultimately, anti-insulin receptor antibodies were found to be present. The patient was treated with glucocorticoids and rituximab. Eight weeks after initiation of immunosuppression, the insulin receptor antibody titer had decreased and hypoglycemia had resolved. Eight months after diagnosis, the patient remained free of severe hypoglycemia despite tapering of glucocorticoids to a near-physiologic dose. Though antibodies to the insulin receptor typically cause severe insulin resistance, this patient had no evidence of insulin resistance and instead presented with recurrent severe hypoglycemia, which responded to glucocorticoids and rituximab. The diagnosis of insulin receptor antibody–mediated hypoglycemia is rare but should be considered in patients with systemic autoimmune disease, including mixed connective tissue disease, in the appropriate clinical context.
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Affiliation(s)
- Max C Petersen
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Jonah M Graves
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Tony Yao
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Waldemar B Minich
- Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Deborah L Parks
- Division of Rheumatology, Washington University School of Medicine, St Louis, MO 63110, USA
| | - Janet B McGill
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Maamoun Salam
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St Louis, Missouri 63110, USA
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Garcia-Avila S, Samuel A, Farooqi I, Manickam R, Ismail M, Khaddash SI, Gibiezaite S. Searching for the Culprit: When Diabetic Ketoacidosis Presents With Insulin Autoantibodies. AACE Clin Case Rep 2020; 7:158-162. [PMID: 34095477 PMCID: PMC8053616 DOI: 10.1016/j.aace.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective The main objective was to describe and review a unique case that presented with diabetic ketoacidosis, positive insulin autoantibodies (IAAbs, which are found in Hirata disease and are usually present with hypoglycemia), and laboratory findings characteristic of type B insulin resistance syndrome (TBIRS) and systemic lupus erythematosus. Confirmation of TBIRS was obtained in Germany as immunoassay for insulin receptor antibodies (IRAbs) is not available in the United States. Methods A literature review on TBIRS and cases that present with IAAbs and IRAbs simultaneously was conducted. Results We found 6 cases presenting with hypoglycemia, both antibodies, and treatment attempts with various management approaches that were different from the proposed National Institutes of Health (NIH) protocol for TBIRS. Our case is distinct because of the demographic background, presentation with diabetic ketoacidosis, comparatively lower insulin requirement, and no significant hypoglycemic episodes in the third phase. Conclusion We propose that access to IRAb immunoassays may be important for diagnosing milder cases of TBIRS, while IAAbs may provide prognostic and therapeutic insights. Despite completely different presentation from other TBIRS patients reviewed, we observed that the proposed NIH protocol consisting of dexamethasone, rituximab, and cyclophosphamide was successfully employed in our patient. Thus, we propose that our case and the findings regarding antibody testing and the NIH treatment regimen may assist clinicians with earlier recognition and effective management of milder cases of TBIRS.
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Affiliation(s)
| | - Anish Samuel
- Department of Medicine, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Iqra Farooqi
- Department of Medicine, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Rajapriya Manickam
- Department of Medicine, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Mourad Ismail
- Department of Medicine, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Saleh I Khaddash
- Department of Medicine, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Sandra Gibiezaite
- Department of Medicine, St. Joseph's University Medical Center, Paterson, New Jersey
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Martins LM, Fernandes VO, de Carvalho MMD, Gadelha DD, de Queiroz PC, Montenegro RM. Type B insulin resistance syndrome: a systematic review. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2020; 64:337-348. [PMID: 32813762 PMCID: PMC10522085 DOI: 10.20945/2359-3997000000257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 03/02/2020] [Indexed: 01/27/2023]
Abstract
A literature review on the clinical, laboratory, and treatment features of type B insulin resistance syndrome (TBIRS). Data from PubMed, the Virtual Health Library and Cochrane database were selected and analyzed using the REDCap application and R statistical program. From 182 papers, 65 were selected, which assessed 119 clinical cases, 76.5% in females and 42.9% in African-Americans, with an average age of 44 years. A common feature of TBIRS is co-occurrence of autoimmune diseases, such as systemic lupus erythematosus (most frequently reported). Hyperglycemia of difficult control was the mostly reported condition. Tests for anti-insulin receptor antibodies were positive in 44.2% of the cases. Disease management comprised fractional diet, insulin therapy (maximum dose given was 57 600 IU/day), plasmapheresis and immunosuppression with several classes of drugs, mainly glucocorticoids. Remission occurred in 69.7% of cases, in 30.3% of these spontaneously. The mortality rate was 15.38%. There was an inverse relationship between anti-insulin antibodies and remission (p = 0.033); and a positive correlation between combined immunosuppressive therapy and remission (p = 0.002). Relapse occurred in 7.6% of the cases. This rare syndrome has difficult-to-control diabetes, even with high doses of insulin, and it is usually associated with autoimmune diseases. Therapeutic advances using immunomodulatory therapy have led to significant improvements in the rate of remission.
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Affiliation(s)
- Luizianne Mariano Martins
- Hospital Universitário Walter CantídioFaculdade de MedicinaUniversidade Federal do CearáFortalezaCEBrasilHospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Virgínia Oliveira Fernandes
- Hospital Universitário Walter CantídioFaculdade de MedicinaUniversidade Federal do CearáFortalezaCEBrasilHospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Manuela Montenegro Dias de Carvalho
- Hospital Universitário Walter CantídioFaculdade de MedicinaUniversidade Federal do CearáFortalezaCEBrasilHospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Daniel Duarte Gadelha
- Hospital Universitário Walter CantídioFaculdade de MedicinaUniversidade Federal do CearáFortalezaCEBrasilHospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Paulo Cruz de Queiroz
- Hospital Universitário Walter CantídioFaculdade de MedicinaUniversidade Federal do CearáFortalezaCEBrasilHospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Renan Magalhães Montenegro
- Hospital Universitário Walter CantídioFaculdade de MedicinaUniversidade Federal do CearáFortalezaCEBrasilHospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
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Anti-Idiotypic Agonistic Antibodies: Candidates for the Role of Universal Remedy. Antibodies (Basel) 2020; 9:antib9020019. [PMID: 32481667 PMCID: PMC7345059 DOI: 10.3390/antib9020019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022] Open
Abstract
Anti-idiotypic antibodies (anti-IDs) were discovered at the very beginning of the 20th century and have attracted attention of researchers for many years. Nowadays, there are five known types of anti-IDs: α, β, γ, ε, and δ. Due to the ability of internal-image anti-IDs to compete with an antigen for binding to antibody and to alter the biologic activity of an antigen, anti-IDs have become a target in the search for new treatments of autoimmune illnesses, cancer, and some other diseases. In this review, we summarize the data about anti-IDs that mimic the structural and functional properties of some bioregulators (autacoids, neurotransmitters, hormones, xenobiotics, and drugs) and evaluate their possible medical applications. The immune system is potentially able to reproduce or at least alter the effects of any biologically active endogenous or exogenous immunogenic agent via the anti-idiotypic principle, and probably regulates a broad spectrum of cell functions in the body, being a kind of universal remedy or immunacea, by analogy to the legendary ancient goddess of universal healing Panacea (Πανάκεια, Panakeia in Greek) in the treatment and prevention of diseases, possibly including non-infectious somatic and even hereditary ones.
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9
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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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Hinke SA, Cieniewicz AM, Kirchner T, D'Aquino K, Nanjunda R, Aligo J, Perkinson R, Cooper P, Boayke K, Chiu ML, Jarantow S, Lacy ER, Liang Y, Johnson DL, Whaley JM, Lingham RB, Kihm AJ. Unique pharmacology of a novel allosteric agonist/sensitizer insulin receptor monoclonal antibody. Mol Metab 2018; 10:87-99. [PMID: 29453154 PMCID: PMC5985231 DOI: 10.1016/j.molmet.2018.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/02/2018] [Accepted: 01/17/2018] [Indexed: 12/12/2022] Open
Abstract
Objective Insulin resistance is a key feature of Type 2 Diabetes (T2D), and improving insulin sensitivity is important for disease management. Allosteric modulation of the insulin receptor (IR) with monoclonal antibodies (mAbs) can enhance insulin sensitivity and restore glycemic control in animal models of T2D. Methods A novel human mAb, IRAB-A, was identified by phage screening using competition binding and surface plasmon resonance assays with the IR extracellular domain. Cell based assays demonstrated agonist and sensitizer effects of IRAB-A on IR and Akt phosphorylation, as well as glucose uptake. Lean and diet-induced obese mice were used to characterize single-dose in vivo pharmacological effects of IRAB-A; multiple-dose IRAB-A effects were tested in obese mice. Results In vitro studies indicate that IRAB-A exhibits sensitizer and agonist properties distinct from insulin on the IR and is translated to downstream signaling and function; IRAB-A bound specifically and allosterically to the IR and stabilized insulin binding. A single dose of IRAB-A given to lean mice rapidly reduced fed blood glucose for approximately 2 weeks, with concomitant reduced insulin levels suggesting improved insulin sensitivity. Phosphorylated IR (pIR) from skeletal muscle and liver were increased by IRAB-A; however, phosphorylated Akt (pAkt) levels were only elevated in skeletal muscle and not liver vs. control; immunochemistry analysis (IHC) confirmed the long-lived persistence of IRAB-A in skeletal muscle and liver. Studies in diet-induced obese (DIO) mice with IRAB-A reduced fed blood glucose and insulinemia yet impaired glucose tolerance and led to protracted insulinemia during a meal challenge. Conclusion Collectively, the data suggest IRAB-A acts allosterically on the insulin receptor acting non-competitively with insulin to both activate the receptor and enhance insulin signaling. While IRAB-A produced a decrease in blood glucose in lean mice, the data in DIO mice indicated an exacerbation of insulin resistance; these data were unexpected and suggested the interplay of complex unknown pharmacology. Taken together, this work suggests that IRAB-A may be an important tool to explore insulin receptor signaling and pharmacology. A novel anti-insulin receptor monoclonal antibody (IRAB-A) was identified that has both agonist and sensitizing activities. IRAB-A increases the receptor's affinity for insulin by binding to an allosteric site and does not compete with insulin. Mice injected once with IRAB-A show improved glycemia and reduced insulinemia, indicative of enhanced insulin sensitivity. In diet induced obese mice, the insulin sensitizing effect of IRAB-A appears to depend on the degree of insulin resistance. Chronic treatment of obese mice showed mixed effects on glucose homeostasis under normal fed or meal challenged conditions.
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Affiliation(s)
- Simon A Hinke
- Cardiovascular and Metabolism Therapeutic Area, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House, PA, 19477, USA.
| | - Anne M Cieniewicz
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Thomas Kirchner
- Cardiovascular and Metabolism Therapeutic Area, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House, PA, 19477, USA
| | - Katharine D'Aquino
- Cardiovascular and Metabolism Therapeutic Area, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House, PA, 19477, USA
| | - Rupesh Nanjunda
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Jason Aligo
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Robert Perkinson
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Philip Cooper
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Ken Boayke
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Mark L Chiu
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Steve Jarantow
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Eilyn R Lacy
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Yin Liang
- Cardiovascular and Metabolism Therapeutic Area, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House, PA, 19477, USA
| | - Dana L Johnson
- Cardiovascular and Metabolism Therapeutic Area, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House, PA, 19477, USA
| | - Jean M Whaley
- Cardiovascular and Metabolism Therapeutic Area, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House, PA, 19477, USA
| | - Russell B Lingham
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA
| | - Anthony J Kihm
- Janssen BioTherapeutics, Janssen Pharmaceutical Research & Development LLC, 1400 McKean Road, Spring House PA 19477, USA.
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Huang Q, Yan Y, Zhao H, Zuo L. A systemic lupus erythematosus patient presenting as type B insulin resistance complicated with cryoglobulinemia. Lupus 2017; 26:95-97. [PMID: 27416845 DOI: 10.1177/0961203316655209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/04/2016] [Indexed: 02/05/2023]
Abstract
Systemic lupus erythematosus (SLE) patients may present with various symptoms and multisystem damage. We reported a 63-year-old male patient with SLE presenting as type B insulin resistance (TBIR) complicated with cryoglobulinemia. TBIR is an extremely rare disease, which is a manifestation of anti-insulin receptor antibodies (AIRA). Clinical feature is a sudden onset of hyperglycemia with major weight loss; however, the ensuing refractory hypoglycemia is more fatal. The average dosage of exogenous insulin is 5100 U/d. SLE patients with AIRA had poor prognosis, most of whom died of SLE activity. Cryoglobulins are immunoglobulins that reversibly precipitate in the cold, which will induce clinical symptoms. Non-infectious mixed cryoglobulinemia is frequently secondary to autoimmune diseases, such as SLE. Our patient was prescribed methylprednisolone (MP) and cyclophosphamide (CTX). Finally he had remission during the short-term follow-up. To our knowledge, this is the first case report of an SLE patient presenting as TBIR complicated with cryoglobulinemia.
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Affiliation(s)
- Q Huang
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China
| | - Y Yan
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - H Zhao
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - L Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
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Chen PH, Wang JS, Hwang JI, Lin SY, Sheu WHH, Wu YJ, Peng CM, Lee IT. Insulinoma in a young female patient with systemic lupus erythematosus: a case report. Endocr Pract 2014; 20:e256-9. [PMID: 25148817 DOI: 10.4158/ep14181.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Fasting hypoglycemia may occur in subjects with systemic lupus erythematosus (SLE) when accompanied with insulin-binding antibodies or insulin-receptor antibodies. However, insulinoma has not been reported in SLE subjects with hypoglycemia. METHODS We present a case report and review the relevant literature. RESULTS A 26-year-old female with underlying SLE experienced several episodes of neuropsychiatric symptoms in a fasting state. The steroid dosage was titrated up, but in vain. Timely imaging studies showed a pancreatic tumor, and insulinoma was proven by pathology. Hypoglycemia did not recur after surgery. CONCLUSION Physicians should distinguish insulinoma from autoimmunity-mediated hypoglycemia in SLE patients with fasting hypoglycemia.
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Affiliation(s)
- Po-Hsun Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jun-Sing Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-I Hwang
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Yi Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wayne H-H Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ya-Ju Wu
- Department of Pathology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Ming Peng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - I-Te Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan School of Medicine, National Yang-Ming University, Taipei, Taiwan School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Kim SW, Won HK, Seok H, Lee BW, Jung CH, Lee WJ, Kim JH. High prevalence of both anti-insulin and anti-insulin receptor antibodies in Korean patients with insulin autoimmune syndrome. Diabetes Res Clin Pract 2012; 98:e12-5. [PMID: 23000370 DOI: 10.1016/j.diabres.2012.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/28/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Abstract
We performed a retrospective pooled analysis of 28 patients who had been diagnosed with insulin autoimmune syndrome and evaluated the prevalence of anti-insulin receptor antibodies. Dual positivity for anti-insulin and anti-insulin receptor antibodies was common (53.8%). However, these patients had a similar phenotype compared with insulin receptor antibody-negative patients.
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Affiliation(s)
- Se Won Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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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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Abstract
Insulinomas are rare causes of hypoglycemia. After having ruled out non insulinomatous causes of hypoglycemia in a patient in whom Whipple's triad is documented, hyperinsulinism must be demonstrated biochemically, either during a spontaneous hypoglycemic episode or, more often, during a supervised fast which may be prolonged up to 72 h. A mixed-meal test may also help to diagnose the very rare cases of postprandial hypoglycemia related to non insulinoma pancreatogenic hypoglycemic syndrome (NIPHS) or to some rare insulinomas. Only when diagnosis of hypoglycemic hyperinsulinism is made, the tumor localization process may be initiated. This may be difficult due to the small size of insulinomas (generally < 1 cm). Multimodal approach is necessary. The association of endoscopic ultrasound and CT-scan or MRI seems optimal. Octreoscan will be also performed. First results with a very new technique, the GLP-1 receptor imaging, are promising for localizing very small tumors. This localization aims to allow a sparing surgery; enucleation of benign tumors, if possible, allows a pancreatic tissue preservation in patients with quite normal survival.
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Affiliation(s)
- L Cazabat
- Hôpitaux de Paris, Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre et Faculté de Médicine Paris-Sud, Université Paris Sud 11, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France.
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