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Hsieh YS. Safety of Antithyroid Drugs in Avoiding Hyperglycemia or Hypoglycemia in Patients With Graves' Disease and Type 2 Diabetes Mellitus: A Literature Review. Cureus 2023; 15:e41017. [PMID: 37519546 PMCID: PMC10372709 DOI: 10.7759/cureus.41017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
Graves' disease (GD) may increase the difficulty of glucose control in patients with type 2 diabetes mellitus (T2DM). Therefore, selecting a drug with limited blood glucose side effects is an important issue in patients with T2DM and GD. Antithyroid drugs (ATDs) including propylthiouracil (PTU), methimazole, and carbimazole are commonly prescribed for the treatment of GD. Here, we review and summarize the literature from the last 10 years and discuss the effects of current ATDs used for GD for blood glucose control in patients with T2DM. A search of the literature published between January 1, 2012 and December 1, 2022 was conducted using three major medical databases: Google Scholar, Ovid Medline, and Scopus. An initial search was conducted on PubMed using the MeSH terms "propylthiouracil," "methimazole," "carbimazole," and "hyperglycemia" or "hypoglycemia" in academic databases. All articles included "Graves' disease" and "type 2 diabetes mellitus" in the title. Based on the results of previous studies, the hyperglycemic and hypoglycemic side effects of ATDs can be explained by several possible mechanisms. The most widely accepted hypothesis is that sulfhydryl group drugs (e.g., methimazole and carbimazole) cleave the disulfide bond of insulin and enhance its immunogenicity, resulting in hypoglycemia. Moreover, some reports have indicated that methimazole is associated with hypoglycemia; therefore, if the patient has a history of autoimmune diseases, it is necessary to consider whether to change drugs or actively track the production of autoimmune antibodies. In non-diabetic and diabetic patients with GD, the hyperglycemic and hypoglycemic side effects of PTU (on glycemic variation) were less than that of thiamazole. However, as relatively few reports have investigated the side effects of blood sugar changes, further research is necessary to confirm these effects. In addition to autoimmune diseases, drug side effects may need to be considered. These findings provide considerations for clinicians to select more appropriate ATDs for patients with GD and T2DM, and implement improved care guidelines.
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Affiliation(s)
- Yu-Shan Hsieh
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, TWN
- Department of Research, Taipei Medical University Hospital, Taipei City, TWN
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Lin M, Chen Y, Ning J. Insulin Autoimmune Syndrome: A Systematic Review. Int J Endocrinol 2023; 2023:1225676. [PMID: 36844104 PMCID: PMC9946739 DOI: 10.1155/2023/1225676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
Insulin autoimmune syndrome (IAS) is a rare endocrine disorder characterized by recurrent episodes of severe hypoglycemia, markedly elevated serum insulin, and positive insulin autoantibodies. In recent years, various countries have reported it one after another. It can be seen that we must pay attention to this disease. The diagnosis of IAS is challenging, requiring a careful workup aimed at excluding other causes of hyperinsulinemic hypoglycemia. High levels of insulin autoantibodies are found in patients, and C-peptide is not parallel to insulin, which could be diagnostic. IAS is a self-limiting disease with a good prognosis. Its treatment mainly includes symptomatic supportive treatment, such as adjusting the diet and using acarbose and other drugs to delay the absorption of glucose to prevent hypoglycemia. For patients with severe symptoms, available treatments may include drugs that reduce pancreatic insulin secretion (such as somatostatin and diazoxide), immunosuppressants (glucocorticoids, zaprin, and rituximab), and even plasma exchange to remove autoantibodies from the body. This review provides a comprehensive analysis of the epidemiology, pathogenesis, clinical manifestations, diagnosis and identification, and monitoring and treatment management of IAS.
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Affiliation(s)
- MingXu Lin
- Department of Endocrinology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen 518110, Guangdong, China
| | - YuHua Chen
- Guangdong Medical University, Zhanjiang 524000, Guangdong, China
- Department of Endocrinology, Longgang District People's Hospital of Shenzhen, Shenzhen 518172, Guangdong, China
| | - Jie Ning
- Department of Endocrinology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen 518110, Guangdong, China
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Wu HY, Chen IH, Lee MY. Case report: hypoglycemia secondary to methimazole-induced insulin autoimmune syndrome in young Taiwanese woman with Graves' disease. Medicine (Baltimore) 2022; 101:e29337. [PMID: 35758364 PMCID: PMC9276182 DOI: 10.1097/md.0000000000029337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Hypoglycemia is an emergent condition with many causes, including underlying diabetes mellitus either with the use of insulin or oral anti-diabetic medications for glucose control, and organ (heart, hepatic, or renal) failure. Insulin autoimmune syndrome (IAS) can also cause hypoglycemia, however it is relatively difficult to diagnose as it is rare clinically. Although uncommon, IAS can be life threatening in patients with persistent hypoglycemia. PATIENT CONCERN We report the case of a 27-year-old female with underlying Graves' disease who was treated with methimazole (MTZ). After 6 weeks of treatment, she developed hypoglycemia symptoms accompanied by dizziness and cold sweating. We excluded underlying diabetes mellitus, the use of insulin or oral anti-diabetic medications, and organ failure. DIAGNOSES Laboratory data showed elevated insulin and C-peptide levels. Therefore, insulinoma and IAS were suspected. Abdominal computed tomography and magnetic resonance imaging ruled out insulinoma, and MTZ-induced IAS was finally diagnosed. INTERVENTIONS AND OUTCOMES The hypoglycemia symptoms resolved after MTZ was switched to propylthiouracil, confirming the diagnosis of IAS. LESSONS This case emphasizes the significance of life-threatening MTZ-induced IAS. IAS should be suspected in patients who develop spontaneous hypoglycemia, especially in those with underlying Graves' disease receiving MTZ who present with hyperinsulinism.
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Affiliation(s)
- Hsuan-Yu Wu
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Hua Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Yueh Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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4
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Sun L, Fang W, Yi D, Sun W, Wang C. Analysis of the clinical characteristics of insulin autoimmune syndrome induced by methimazole. J Clin Pharm Ther 2020; 46:470-475. [PMID: 33119911 DOI: 10.1111/jcpt.13307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/31/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The number of case reports of insulin autoimmune syndrome (IAS) induced by methimazole (MMI) is increasing. The purpose of this study is to explore the clinical characteristics and provide a scientific reference for clinical diagnosis, treatment and prevention. METHODS The literature on IAS cases and case series induced by MMI in Chinese and English was collected for retrospective analysis. RESULTS AND DISCUSSION A total of 106 patients (males 33, females 73) were described in the Chinese and English literature. The median age of patients with IAS induced by MMI was 37 years (range 15-76) occurring during both regular and irregular MMI therapy or after resumption of medication. The onset of symptoms occurred at night or early morning, within days in some and up to 6 months in others; the symptoms were neuropathic in 65.31% and related to the autonomic nervous system in 33.67%. Blood glucose concentration in samples presumably taken during the hypoglycaemic phase was 1.7 mmol/L (median; range 0.03-4.7); insulin concentrations were elevated ≥100 mU/L (ref range) and associated with low C-peptide levels (<10 μg/L; ref range). Tests for IgG insulin autoantibodies (IAA) were positive in 104 patients (98.02%) and negative in two patients (1.98%). The 75-g oral glucose tolerance test (OGTT) showed impaired glucose tolerance and diabetic curves. Pancreatic imaging was unremarkable on computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Withdrawal of MMI alone or with corticosteroid treatment reduced hypoglycaemic episodes within days to 3 months. IAA decreased and became negative in 3 months (median; range 1-12). Follow-up showed no recurrent hypoglycaemic episodes at 5 months (median; range 1-60). WHAT IS NEW AND CONCLUSION Methimazole-induced IAS is a clinically rare autoimmune disease with hypoglycaemia that occurs during medication treatment that should be treated promptly.
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Affiliation(s)
- Linli Sun
- Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Dan Yi
- Drug Clinical Trial Center, Zhuzhou Central Hospital, Zhuzhou, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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Preoperative plasmapheresis experience in Graves' disease patients with anti-thyroid drug-induced hepatotoxicity. Transfus Apher Sci 2020; 59:102826. [PMID: 32532690 DOI: 10.1016/j.transci.2020.102826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 11/27/2022]
Abstract
Hepatotoxicity is a rare but serious side effect of antithyroid drug (ATI) therapy in Graves' disease patients. Cessation of ATI drug is needed in most of the patients if liver enzymes highly elevated or in case of agranulocytosis. Permanent therapy, surgery or radioactive iodine ablation are the treatment choices to ensure euthyroidism in active Graves' disease patients. Therapeutic plasma exchange (TPE) can be an option to ensure euthyroidism, especially in patients scheduled for urgent surgery. In the present study, we present consecutive five cases of methimazole related severe hepatotoxicity that underwent TPE before thyroid surgery. The median number of apheresis sessions was 3 (range: 2-5). Free triiodothyronine (FT3) 65-83 %, free thyroxine (FT4) 22-66 %, thyrotropin receptor antibodies (TRAB) 55-96 % decreases were observed. All patients underwent total thyroidectomy. TPE is an effective method to reduce serum FT3, FT4, TRAB levels in the short term to provide better thyroid hormone status before urgent surgery in ATI induced toxic hepatitis patients.
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Shen Y, Song X, Ren Y. Insulin autoimmune syndrome induced by exogenous insulin injection: a four-case series. BMC Endocr Disord 2019; 19:148. [PMID: 31883520 PMCID: PMC6935495 DOI: 10.1186/s12902-019-0482-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia and is characterized by the presence of insulin autoantibodies. Patients with IAS usually complain of hypoglycemia without any previous insulin received. Glucocorticoids and immunosuppressants are used to treat IAS. CASE PRESENTATION We report four patients with diabetes who were diagnosed with non-classical IAS and describe the treatment of these patients. Moreover, the differential diagnosis with hyperinsulinism is discussed. CONCLUSION High levels of insulin autoantibodies, as well as hyperinsulinemic hypoglycemia, are found in patients with diabetes mellitus and prior exogenous insulin exposure. This situation that we classified as non-classical IAS should be attached importance to.
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Affiliation(s)
- Yimin Shen
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
- Zhejiang University School of Medicine, Zhejiang, 310058 China
| | - Xiaoxiao Song
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
| | - Yuezhong Ren
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
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Gao G, Li FF, Hu Y, Yan RN, Liu BL, Liu XM, Su XF, Ma JH, Hu G. Glycemic variation in uncontrolled Graves' disease patients with normal glucose metabolism: Assessment by continuous glucose monitoring. Endocrine 2019; 64:265-270. [PMID: 30515677 PMCID: PMC6531392 DOI: 10.1007/s12020-018-1820-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 11/12/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To observe the glycemic variation (GV) in uncontrolled Graves' disease (GD) patients with normal glucose metabolism measured by continuous glucose monitoring (CGM). METHODS This was a single-center, open-label, observational study. From January 2017 to October 2017, 20 GD patients with normal glucose metabolism and 24 healthy control subjects were recruited. Serum samples were obtained at 0, 30, and 120 min after oral glucose loading for glucose, insulin, and C-peptide level measurements. Fasting plasma fasting free triiodothyronine (FT3), free thyroxin (FT4), and thyroid stimulating hormone concentrations were also detected. All participants were subjected to a 3-day CGM after baseline data were collected. The primary endpoint was the difference in the mean amplitude of the glycemic excursions between the two groups. RESULTS Compared with the healthy subjects, the GD patients had higher mean amplitude of glycemic excursions (MAGE) (P < 0.01). Multiple linear stepwise regression analysis showed that FT4 level was an independent factor for the MAGE. Interestingly, the GD patients had a significant prolongation in the time to peak glucose, especially after breakfast (P < 0.01), and the elevation in the incremental area under the curve of glucose after breakfast till 4 hours later. CONCLUSIONS Uncontrolled GD patients with normal glucose metabolism had a greater GV, and the FT4 level may contributed to the increased GV.
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Affiliation(s)
- Gu Gao
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Neurodegeneration, Department of Pharmacology, Nanjing Medical University, Nanjing, China
| | - Feng-Fei Li
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yun Hu
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Reng-Na Yan
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Bing-Li Liu
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Mei Liu
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Fei Su
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jian-Hua Ma
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - Gang Hu
- Jiangsu Key Laboratory of Neurodegeneration, Department of Pharmacology, Nanjing Medical University, Nanjing, China.
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Church D, Cardoso L, Kay RG, Williams CL, Freudenthal B, Clarke C, Harris J, Moorthy M, Karra E, Gribble FM, Reimann F, Burling K, Williams AJK, Munir A, Jones TH, Führer D, Moeller LC, Cohen M, Khoo B, Halsall D, Semple RK. Assessment and Management of Anti-Insulin Autoantibodies in Varying Presentations of Insulin Autoimmune Syndrome. J Clin Endocrinol Metab 2018; 103:3845-3855. [PMID: 30085133 PMCID: PMC6179165 DOI: 10.1210/jc.2018-00972] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/26/2018] [Indexed: 01/01/2023]
Abstract
Context Insulin autoimmune syndrome (IAS), spontaneous hyperinsulinemic hypoglycemia due to insulin-binding autoantibodies, may be difficult to distinguish from tumoral or other forms of hyperinsulinemic hypoglycemia, including surreptitious insulin administration. No standardized treatment regimen exists. Objectives To evaluate an analytic approach to IAS and responses to different treatments. Design and Setting Observational study in the UK Severe Insulin Resistance Service. Patients Six patients with hyperinsulinemic hypoglycemia and detectable circulating anti-insulin antibody (IA). Main Outcome Measures Glycemia, plasma insulin, and C-peptide concentrations by immunoassay or mass spectrometry (MS). Immunoreactive insulin was determined in the context of polyethylene glycol (PEG) precipitation and gel filtration chromatography (GFC). IA quantification using ELISA and RIA, and IA were further characterized using radioligand binding studies. Results All patients were diagnosed with IAS (five IgG, one IgA) based on a high insulin/C-peptide ratio, low insulin recovery after PEG precipitation, and GFC evidence of antibody-bound insulin. Neither ELISA nor RIA result proved diagnostic for every case. MS provided a more robust quantification of insulin in the context of IA. One patient was managed conservatively, four were treated with diazoxide without sustained benefit, and four were treated with immunosuppression with highly variable responses. IA affinity did not appear to influence presentation or prognosis. Conclusions IAS should be considered in patients with hyperinsulinemic hypoglycemia and a high insulin/C-peptide ratio. Low insulin recovery on PEG precipitation supports the presence of insulin-binding antibodies, with GFC providing definitive confirmation. Immunomodulatory therapy should be customized according to individual needs and clinical response.
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Affiliation(s)
- David Church
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Academic Endocrine Unity, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Richard G Kay
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
| | - Claire L Williams
- Diabetes & Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Bernard Freudenthal
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Catriona Clarke
- Department of Clinical Biochemistry, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Julie Harris
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Myuri Moorthy
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Efthmia Karra
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Fiona M Gribble
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Frank Reimann
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Keith Burling
- Core Biochemical Assay Laboratory, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Alistair J K Williams
- Diabetes & Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Alia Munir
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - T Hugh Jones
- Robert Hague Centre for Diabetes and Endocrinology, Barnsley Hospital, NHS Foundation Trust, Barnsley, United Kingdom
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lars C Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Mark Cohen
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Bernard Khoo
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - David Halsall
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Robert K Semple
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
- University of Edinburgh Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, United Kingdom
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Censi S, Mian C, Betterle C. Insulin autoimmune syndrome: from diagnosis to clinical management. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:335. [PMID: 30306074 DOI: 10.21037/atm.2018.07.32] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Autoimmune forms of hypoglycemia are a rare cause of low blood sugar levels among Caucasians, and often go misdiagnosed, exposing patients to lengthy series of pointless, potentially harmful and expensive tests. There are two types of autoimmune hypoglycemia. One is insulin autoimmune syndrome (IAS), which is characterized by hyperinsulinemic hypoglycemia, elevated insulin autoantibody (IAA) titers, no prior exposure to exogenous insulin, and no of pathological abnormalities of the pancreatic islets. This condition is also known as "Hirata's disease". The other is type B insulin resistance syndrome (TBIRS), a rare autoimmune disorder resulting in a broad array of abnormalities in glucose homeostasis-from hypoglycemia to extremely insulin-resistant hyperglycemia-caused by the presence of insulin receptor autoantibodies (IRAbs). This review focuses on these two syndromes, describing their epidemiology, possible genetic background, clinical presentation, pathophysiology, diagnosis and treatment.
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Affiliation(s)
- Simona Censi
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Caterina Mian
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Corrado Betterle
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
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Kittah NE, Vella A. MANAGEMENT OF ENDOCRINE DISEASE: Pathogenesis and management of hypoglycemia. Eur J Endocrinol 2017; 177:R37-R47. [PMID: 28381450 DOI: 10.1530/eje-16-1062] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/15/2017] [Accepted: 04/05/2017] [Indexed: 01/03/2023]
Abstract
Glucose is the main substrate utilized by the brain and as such multiple regulatory mechanisms exist to maintain glucose concentrations. When these mechanisms fail or are defective, hypoglycemia ensues. Due to these robust mechanisms, hypoglycemia is uncommon and usually occurs in the setting of the treatment of diabetes using glucose-lowering agents such as sulfonylureas or insulin. The symptoms of hypoglycemia are non-specific and as such it is important to confirm hypoglycemia by establishing the presence of Whipple's triad before embarking on an evaluation for hypoglycemia. When possible, evaluation of hypoglycemia should be carried out at the time of spontaneous occurrence of symptoms. If this is not possible then one would want to create the circumstances under which symptoms occur. In cases where symptoms occur in the post absorptive state, a 72-h fast should be performed. Likewise, if symptoms occur after a meal then a mixed meal study may be the test of choice. The causes of endogenous hyperinsulinemic hypoglycemia include insulinoma, post-bariatric hypoglycemia and noninsulinoma pancreatogenous hypoglycemia syndrome. Autoimmune hypoglycemia syndrome is clinically and biochemically similar to insulinoma but associated with high levels of insulin antibodies and plasma insulin. Other important causes of hypoglycemia include medications, non-islet cell tumors, hormonal deficiencies, critical illness and factitious hypoglycemia. We provide an overview of the pathogenesis and management of hypoglycemia in these situations.
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Affiliation(s)
- Nana Esi Kittah
- Division of EndocrinologyDiabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of EndocrinologyDiabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Su CT, Lin YC. Hyperinsulinemic hypoglycemia associated with insulin antibodies caused by exogenous insulin analog. Endocrinol Diabetes Metab Case Rep 2016; 2016:EDM160079. [PMID: 27933175 PMCID: PMC5118974 DOI: 10.1530/edm-16-0079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/02/2016] [Indexed: 11/08/2022] Open
Abstract
Insulin antibodies (IA) associated with exogenous insulin administration seldom caused hypoglycemia and had different characteristics from insulin autoantibodies (IAA) found in insulin autoimmune syndrome (IAS), which was first described by Dr Hirata in 1970. The characteristic of IAS is the presence of insulin-binding autoantibodies and related fasting or late postprandial hypoglycemia. Here, we report a patient with type 1 diabetes mellitus under insulin glargine and insulin aspart treatment who developed recurrent spontaneous post-absorptive hyperinsulinemic hypoglycemia with the cause probably being insulin antibodies induced by exogenous injected insulin. Examinations of serial sera disclosed a high titre of insulin antibodies (33%, normal <5%), high insulin concentration (111.9 IU/mL) and undetectable C-peptide when hypoglycemia occurred. An oral glucose tolerance test revealed persistent high serum levels of total insulin and undetectable C-peptide. Image studies of the pancreas were unremarkable, which excluded the diagnosis of insulinoma. The patient does not take any of the medications containing sulfhydryl compounds, which had been reported to cause IAS. After administering oral prednisolone for 3 weeks, hypoglycemic episodes markedly improved, and he was discharged smoothly. LEARNING POINTS Insulin autoimmune syndrome (IAS) or IAS-like situation should be one of the differential diagnosis in patients with hyperinsulinemic hypoglycemia.Although less reported, insulin antibodies (IA) caused by exogenous insulin analog should be considered as the cause of hypoglycemia.Patients with suspected insulin autoimmune syndrome (IAS) should be screened for drugs related to autoimmunity to endogenous insulin.
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Affiliation(s)
- Chih-Ting Su
- Faculty of Medicine , National Yang-Ming University, Taipei , Taiwan
| | - Yi-Chun Lin
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Medicine, Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1268] [Impact Index Per Article: 158.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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13
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Yamada E, Okada S, Saito T, Osaki A, Ozawa A, Yamada M. Insulin autoimmune syndrome during the administration of clopidogrel. J Diabetes 2016; 8:588-9. [PMID: 26847582 DOI: 10.1111/1753-0407.12385] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 01/28/2016] [Indexed: 01/29/2023] Open
Affiliation(s)
- Eijiro Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Shuichi Okada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Tsugumichi Saito
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Aya Osaki
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Atushi Ozawa
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
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14
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Han JS, Moon HJ, Kim JS, Kim HI, Kim CH, Kim MJ. Anti-tuberculosis Treatment-Induced Insulin Autoimmune Syndrome. THE EWHA MEDICAL JOURNAL 2016. [DOI: 10.12771/emj.2016.39.4.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jung Suk Han
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Han Ju Moon
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Seo Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Hong Il Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Cheol Hyeon Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Min Joo Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
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15
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Lee WY. Brief review of articles in 'endocrinology and metabolism' in 2013. Endocrinol Metab (Seoul) 2014; 29:251-6. [PMID: 25309783 PMCID: PMC4192822 DOI: 10.3803/enm.2014.29.3.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Won-Young Lee
- Department of Endocrinology and Metabolism, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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