Solitary pancreas transplantation for life-threatening allergy to human insulin*

Abstract

Summary We report on a 30‐year‐old man, with type 1 diabetes mellitus, who developed generalized allergy to insulin consisting of several bouts of tremor, tachycardia, breathlessness and syncope. Strong positive reactions to protamine and metacresol were demonstrated by skin‐prick testing. Symptoms persisted despite the use of antihistamine therapy, Actrapid HM Paraben® and Monotard® (insulin without protamine and metacresol) and immunosuppression (tacrolimus). He underwent a cadaver pancreas transplantation with portal‐enteric drainage in June 2003. Following the antithymocyte globulin induction, immunosuppression consisted in tacrolimus and sirolimus without steroids. The patient subsequently reported a complete resolution of his symptoms and excellent glycaemic control. Thirteen months after transplantation, the patient developed oral ulcerations and severe leucopoenia initially attributed to sirolimus, which was subsequently stopped. A hyperglycaemic episode following corticosteroid therapy for acute rejection therapy required the reintroduction of insulin. Allergic manifestations reappeared promptly. Currently, 2 years after transplantation, the patient is euglycaemic without insulin (glycated haemoglobin 5.8%) and he is free of allergic reactions.

Allergic reactions to human insulin: a review of current knowledge and treatment options

“…Tacrolimus aiming for serum trough levels between 5 and 10 ng/ml was given to a patient with generalized insulin allergy; however no improvement of his symptomatology was observed [65]. In a very recent paper, Yong et al [66] reported a patient with severe generalized insulin allergy who was treated successfully by the sequential use of two targeted biologic agents, rituximab and omalizumab, in a two-step therapeutic approach which also consisted of the use of prednisolone and mycophenolate mofetil.…”

Type III Hypersensitivity Reaction to Subcutaneous Insulin Preparations in a Type 1 Diabetic

“…Pancreas transplantation would theoretically eliminate the need for subcutaneous insulin; however, this entails significant surgical risks and long-term immunosuppression that must be considered. 16,17 Intraperitoneal administration of insulin via continuous intraperitoneal insulin infusion (CIPII) with an implantable insulin pump has been studied to improve glycemic control in patients with type 1 diabetes mellitus for whom other therapies have failed, although this treatment is neither cost effective nor widely available. 18 Lastly, inhaled insulin would appear to be an attractive option for patients with cutaneous hypersensitivity reactions to insulin, although to our knowledge no data exist evaluating its use in such patients, and it can currently be found only as a short-acting formulation.…”

Pan-insulin allergy and severe lipoatrophy complicating Type 2 diabetes

“…In conjunction with definitive therapy, non-specific treatments such as anti-histamines and immunosuppressants [25] may be required. In some very severe cases of allergy, extreme measures have been resorted to, including the use of biologic agents (rituximab and omalizumab) [28] and even pancreatic transplant [29].…”