A subset of patients with type 2 diabetes have a more extreme form of insulin resistance. Such patients require in excess of 200 units/day of insulin. The large volume of insulin required can cause problems with absorption and is often painful, affecting patient concordance. These patients often have poor glycaemic control. U‐500 insulin in equivalent doses delivers one‐fifth of the volume of regular U‐100 insulin and can potentially improve glycaemic control. Use of insulin pumps allows continuous infusion of U‐500 insulin resulting in better absorption and ability to deliver larger volumes over a 24‐hour period. There are a few case reports of U‐500 insulin delivered via pump, which have shown improvement in glycaemic control and patients' quality of life. We present a case of extreme insulin resistance in a female patient whose glycaemic control improved remarkably using insulin pump. She also reported subjective improvement in her quality of life. Copyright © 2009 John Wiley & Sons.

Since the introduction of insulin analogues, there have been several published case reports of overdoses with this medication. Refractory hypoglycaemia with potentially serious neurological sequelae, including death, can occur in severe insulin overdoses. Around 30 years ago, long before insulin analogues were available, several authors reported that the excision of the soft tissue at the injection site lowered plasma insulin concentrations in overdoses with conventional short‐acting and depot insulin. In a suicide attempt, an 18‐year‐old man had injected himself with a large amount of insulin analogues into the abdominal wall; 50 minutes after the overdose he became hypoglycaemic. He was commenced on an intravenous infusion of glucose and the injection site was surgically excised. Serial serum insulin concentrations were measured. After the excision of the insulin injection site, serum insulin concentrations fell from 4220 to 88pmol/L within 2.5 hours. Those results were only available after several weeks. As a precaution at the time, the glucose infusion had been continued for 67 hours. We observed the last hypoglycaemic event in our patient a few minutes after the surgical intervention. The patient suffered no complications and was discharged following a psychiatric assessment. In retrospect, with the knowledge that our patient's serum insulin concentrations had dramatically fallen after surgical intervention, intravenous glucose could have been stopped earlier. This case report describes a substantial reduction in serum insulin concentrations using surgical excision of the single injection site after a severe overdose of insulin glargine and insulin aspart. Copyright © 2012 John Wiley & Sons.

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The combination of peripheral vascular disease, neuropathy and increased susceptibility to infection are responsible for diabetic foot problems. In patients with evidence of diabetic foot disease, it is important to take measures to keep good care of the hands, which can also be compromised. The hand is a common site for acupuncture. This case report demonstrates serious limb threatening complications following acupuncture treatment for pain from rheumatoid arthritis and sensory neuropathy.