Extreme subcutaneous insulin resistance: a misunderstood syndrome

Soudan, Benoı̂t; Girardot, C; Fermon, C.; Verlet, E.; Pattou, F.; Vantyghem, Marie-Christine

doi:10.1016/s1262-3636(07)70069-1

Cited by 25 publications

(38 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Insulin resistance associated with s.c. insulin administration is another uncommon condition that complicates T1DM management (7). This condition is characterised by decreased sensitivity to s.c., but not i.v.…”

Section: Introductionmentioning

confidence: 99%

Analytical and clinical challenges in a patient with concurrent type 1 diabetes, subcutaneous insulin resistance and insulin autoimmune syndrome

Jassam

Amin

Holland

et al. 2014

Endocrinology, Diabetes &Amp; Metabolism Case Reports

View full text Add to dashboard Cite

SummaryA lean 15-year-old girl was diagnosed with type 1 diabetes based on symptomatic hyperglycaemia and positive anti-islet cell antibodies. Glycaemia was initially stabilised on twice-daily mixed insulin. After 11 months from the time of diagnosis, she complained of hyperglycaemia and ketosis alternating with hypoglycaemia. This progressively worsened until prolonged hospital admission was required for treatment of refractory hypoglycaemia. A high titre of anti-insulin antibodies was detected associated with a very low recovery of immunoreactive (free) insulin from plasma after precipitation with polyethylene glycol, suggesting the presence of insulin in bound complexes. Insulin autoimmune syndrome was diagnosed and metabolic fluctuations were initially managed supportively. However, due to poor glucose control, immunosuppressive therapy was initiated first with steroids and plasmapheresis and later with anti-CD20 antibody therapy (Rituximab). This treatment was associated with a gradual disappearance of anti-insulin antibodies and her underlying type 1 diabetes has subsequently been successfully managed with an insulin pump.Learning points Anti-insulin antibodies may result in low levels of free insulin.Polyclonal anti-insulin antibodies can interfere with the pharmacological action of administered insulin, resulting in hypoglycaemia and insulin resistance, due to varying affinities and capacities.In this patient, rituximab administration was associated with a gradual disappearance of anti-insulin antibodies.It is hypothesised that this patient had subcutaneous insulin resistance (SIR) caused by insulin capture at the tissue level, either by antibodies or by sequestration.A prolonged tissue resistance protocol may be more appropriate in patients with immune-mediated SIR syndrome.

show abstract

Section: Introductionmentioning

confidence: 99%

Analytical and clinical challenges in a patient with concurrent type 1 diabetes, subcutaneous insulin resistance and insulin autoimmune syndrome

Jassam

Amin

Holland

et al. 2014

Endocrinology, Diabetes &Amp; Metabolism Case Reports

View full text Add to dashboard Cite

show abstract

“…(1). Essa rara condição manifesta-se com resistência à ação da insulina no tecido subcutâ-neo (SC), com sensibilidade normal, ou próxima do normal, quando administrada de forma contínua por via endovenosa (2). Além disso, a resistência insulínica pode apresentar-se concomitantemente por via intramuscular (IM) caracterizando o DRIASM (3) .…”

Section: Discussionunclassified

Extrema resistência à insulina subcutânea e intramuscular em diabetes melito tipo 1

Pinheiro

Tácito

Pires

2011

Arq Bras Endocrinol Metab

View full text Add to dashboard Cite

SUMÁRIOResistência insulínica consiste em reduzida resposta celular a esse hormônio e, portanto, disfunção do transporte de glicose para o meio intracelular. Esse fenômeno associa-se a fatores genéticos e principalmente comportamentais relacionados a obesidade e comorbidades a ela associadas como diabetes melito tipo 2, hipertensão arterial e dislipidemia. Entretanto, fatores clínicos de resistência insulínica também estão presentes em diabéticos tipo 1 não obesos na conhecida síndrome de extrema resistência à insulina subcutânea e intramuscular (DRIASM). Condição rara que consiste em resistência à ação da insulina no tecido subcutâneo e muscular e sensibilidade normal, ou próxima do normal, quando administrada via intravenosa. Tratamentos propostos até o momento mostram-se pouco efetivos e se relacionam a complicações e falhas frequentes. Descrevemos dois casos de pacientes femininas de 45 e 46 anos com DRIASM que se diferenciam dos demais já descritos por apresentar diagnóstico de diabetes melito tipo 1 tardio, hiperglicemia constante associada a complicações catabólicas, microvasculares (retinopatia) e neuropáticas sem, no entanto, nenhum episódio de cetoacidose diabética. Os tratamentos propostos variaram desde aplicação de insulina intramuscular e intravenosa até listagem para possível realização de transplante de pâncreas como tentativa de tratamento definitivo. SUMMARYInsulin resistance signs reduced cellular response to this hormone and dysfunction of glucose transport to intracellular compartment. This phenomenon is associated to genetic factors and principally behavior factors correlating to obesity and its comorbidities, as type 2 diabetes mellitus, hypertension and dyslipidemia. However clinical factors of insulin resistance are still present at not obese type 1 diabetes in a known syndrome called type 1 diabetes mellitus with resistance to insulin administered subcutaneously and intramuscularly (DRIASM). This is a rare condition that consists into insulin resistance at subcutaneously and intramuscularly use and normal or near to normal sensitivity at intravenously way. Treatments until now proposed are ineffective and are related to frequent fails and complications. We report here two cases of DRIASM in 45 and 46 female patients that are different from others yet related because they have late diabetes type 1, sustained hyperglycemia associated to catabolic, microangiopathy and neuropathic complications without any ketoacidosis episode. The treatment vary from alternative ways for insulin infusion to inscription to a possible performance of pancreas transplantation like a experiment of definitive treatment. This report was approved by Research Ethic Committee from São José do Rio Preto medical school. Arq Bras Endocrinol Metab. 2011;55(3)

show abstract

“…5 The standard treatments for ESIR include: (1) concentrated regular insulin (U-500) and (2) implantable intraperitoneal delivery; our patient received the former. 6 U-500 use in EIR has been shown to be more cost-effective. 1 Several reports have suggested success with protease inhibitors (aprotinin, nafamostat ointment), plasmapheresis, and intravenous immunoglobulin for extreme SQ resistance.…”

Section: Discussionmentioning

confidence: 99%