scholarly journals Successful management of severe diabetic ketoacidosis in a patient with type 2 diabetes with insulin allergy: a case report

2019 ◽  
Author(s):  
Anh Dat Nguyen ◽  
Chinh Quoc Luong ◽  
Hieu Chu Chi ◽  
Van Khoa Dieu Nguyen ◽  
Chi Van Nguyen ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Metabolic Acidosis ◽  
Allergic Reaction ◽  
Diabetic Ketoacidosis ◽  
Human Insulin ◽  
Insulin Infusion ◽  
Recombinant Human Insulin ◽  
Insulin Allergy ◽  
Allergic Symptoms

Abstract BackgroundDiabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion.Case presentationA 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 minutes of injection and lasting over 24 hours. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 µmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 hours, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites.ConclusionsIn this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.

scholarly journals Successful management of severe diabetic ketoacidosis in a patient with type 2 diabetes with insulin allergy: a case report

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Anh Dat Nguyen ◽  
Chinh Quoc Luong ◽  
Hieu Chi Chu ◽  
Van Khoa Dieu Nguyen ◽  
Chi Van Nguyen ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Metabolic Acidosis ◽  
Allergic Reaction ◽  
Diabetic Ketoacidosis ◽  
Human Insulin ◽  
Insulin Infusion ◽  
Recombinant Human Insulin ◽  
Insulin Allergy ◽  
Allergic Symptoms

Abstract Background Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion. Case presentation A 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 min of injection and lasting over 24 h. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 μmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 h, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites. Conclusions In this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.

scholarly journals Successful management of severe diabetic ketoacidosis in a patient with type 2 diabetes with insulin allergy: a case report

2019 ◽  
Author(s):  
Anh Dat Nguyen ◽  
Chinh Quoc Luong ◽  
Hieu Chu Chi ◽  
Van Khoa Dieu Nguyen ◽  
Chi Van Nguyen ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Metabolic Acidosis ◽  
Allergic Reaction ◽  
Diabetic Ketoacidosis ◽  
Human Insulin ◽  
Insulin Infusion ◽  
Recombinant Human Insulin ◽  
Insulin Allergy ◽  
Allergic Symptoms

Abstract BackgroundDiabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion.Case presentationA 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 minutes of injection and lasting over 24 hours. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 µmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 hours, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites.ConclusionsIn this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.

scholarly journals SUN-693 What Else Should Be Done in Patients with Uncontrolled Type 2 Diabetes and Severe Insulin Allergy?

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Ghada Elshimy ◽  
Ricardo Rafael Correa ◽  
Pawarid Techathaveewat ◽  
Karyne Lima Vinales ◽  
Sherman Mitchell Harman
Keyword(s):  
Type 2 Diabetes ◽  
Allergic Reaction ◽  
Insulin Pump ◽  
Case Reports ◽  
Skin Testing ◽  
Rare Condition ◽  
Inpatient Setting ◽  
Severe Condition ◽  
Insulin Allergy

Abstract Introduction: Insulin allergy in patients with diabetes mellitus is a very rare condition. The immediate vital implications for the patient call for prompt diagnosis and management of insulin allergy. We present a case of a patient that was unable to tolerate the insulin desensitization process, however; he was successfully treated with antidiabetics’ medications following the AACE guidelines for the management of type 2 diabetes (T2DM).Case description:31 years old obese Caucasian male with a BMI of 35, a history of T2DM and insulin allergy who was admitted to the hospital with hyperglycemia and osteomyelitis of the right foot. Endocrinology was consulted for the management of diabetes. Laboratory results showed hemoglobin A1C 11.1%, C peptide level 2.79 with blood glucose 283 mg/dl with negative insulin specific IgG level and elevated Ig E levels. The patient was actually diagnosed with T2DM in 2001, then started on metformin, glyburide initially. Given uncontrolled diabetes he was started on insulin in 2007 however, he developed an allergic reaction to different types of insulin (including anaphylactic reaction) so he was referred to allergy and immunology for further testing and possible desensitization. He had an allergy to human, bovine and porcine insulin. Exclusion of other causes of allergy including latex, protamine, and zinc was performed by the immunologist. Trial of insulin desensitization (using NPH and regular Insulin) failed. He also developed an allergic reaction to different medications including sulfonylurea, SGLT2 inhibitors, DDP4 inhibitors, and alpha-glucosidase inhibitors. During the inpatient setting in 2019, we assessed the patient and considered different options available; bromocriptine versus amylin products versus fish insulin versus IGF1 (as of last resort). Other options were another desensitization process in the ICU setting with transitioning to an insulin pump, however, the patient refused that option. We started the patient on bromocriptine mesylate(cyclocet) with pioglitazone and the A1C improved in the next 3 months from 11.1%-->9.8%. The patient is still following up with us and plans for desensitization once the osteomyelitis of the foot is controlled. Discussion and conclusion: Insulin allergy is a rare but severe condition that calls for immediate work-up. It can be managed well in close cooperation between the endocrinologist and the immunologist. Our patient developed IgE-mediated symptoms occurring immediately after insulin injection and confirmed by intradermal skin testing. Specific immunotherapy has been reported in case reports in the literature and should be considered for these patients Following AACE guidelines for the management of T2DM with the addition of bromocriptine mesylate until desensitization was a beneficial option for our patient.

scholarly journals Diabetic ketoacidosis with acute severe hypertriglyceridaemia-induced pancreatitis as first presentation of type 2 diabetes

2021 ◽  
Vol 14 (4) ◽  
pp. e239727
Author(s):  
Man Tek Kong ◽  
Monica Pon Nunes ◽  
Kan Fat Leong
Keyword(s):  
Type 2 Diabetes ◽  
Supportive Care ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Treatment Modalities ◽  
Inflammatory Condition ◽  
Randomised Trials ◽  
The Third ◽  
Intravenous Insulin

Acute pancreatitis (AP) is an acute destructive inflammatory condition of the pancreas. Hypertriglyceridaemia is the third most common worldwide cause of AP. Although the presentation of hypertriglyceridaemic pancreatitis (HTGP) is usually similar to other forms of AP, it may cause more severe AP and worse symptoms. Therefore, apart from the supportive care and treatment for AP, it is necessary to treat the underlying aetiology. There are no established guidelines for managing HTGP. Many treatment modalities have been reported, including intravenous insulin infusion, heparin and plasmapheresis. Randomised trials comparing their efficacy are lacking. Diabetic ketoacidosis (DKA) may be a risk factor for AP, but it is uncertain if AP triggers DKA or vice versa. Here, we describe a case of a 44-year-old man who presented with DKA concurrent with acute severe HTGP as first manifestation of type 2 diabetes mellitus. He was successfully managed with supportive care and intravenous insulin infusion.

2465-PUB: Successful Management of Severe Diabetic Ketoacidosis in a Type 2 Diabetes Patient with Insulin Allergy

Diabetes ◽  
2019 ◽  
Vol 68 (Supplement 1) ◽  
pp. 2465-PUB ◽  
Author(s):  
ANH D. NGUYEN ◽  
CHINH Q. LUONG ◽  
HIEU C. CHU ◽  
VAN K. NGUYEN ◽  
CHI V. NGUYEN ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Diabetic Ketoacidosis ◽  
Diabetes Patient ◽  
Successful Management ◽  
Insulin Allergy
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