A case of autoimmune hypoglycemia outside Japan: Rare, but in the era of expanding drug-list, important to suspect

Gopal, K.; Priya, Gagan; Gupta, Nidhi; Praveen, EP; Khadgawat, Rajesh

doi:10.4103/2230-8210.122644

Cited by 16 publications

(9 citation statements)

References 5 publications

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“…In a study that included 380 Japanese patients reported that approximately 50% had prior exposure to drugs such as methimazole, penicillamine, glutathione, hydralazine, procainamide and isoniazid. There are case reports of IAS in patients using sulfhydryl-containing proton pump inhibitors including pantoprazole and omeprazole (3, 8). The mechanism of development of IAS with sulfhydryl group-containing drug is not entirely clear.…”

Section: Discussionmentioning

confidence: 99%

“…She lost 6 pounds of weight, her HbA1c improved to 5.7% and anti-insulin antibody levels came down to 33 U/mL. Based on a report of pantoprazole-related IAS cases (3), her omeprazole was switched to an H2 receptor blocker famotidine. Over the next 12 months, she reported only two episodes of hypoglycemia.…”

Section: Outcome and Follow-upmentioning

confidence: 99%

“…Typically, it is known to occur in patients exposed to insulin analogues (1). Other medications such as alpha lipoic acid (2) and sulfa-containing drugs such as procainamide, methimazole and hydralazine have also been found to be associated with IAS (3). We present a rare case of IAS in a patient with morbid obesity and prediabetes and using omeprazole.…”

Section: Introductionmentioning

confidence: 99%

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Insulin Autoimmune Syndrome: a rare cause of postprandial hypoglycemia

Sahni

Trivedi

Omer

2016

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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SummaryA 65-year-old obese Caucasian woman presented with symptomatic postprandial hypoglycemic episodes, resolution of symptoms with carbohydrate intake and significantly elevated anti-insulin antibody levels. She did not have any evidence for the use of oral antidiabetic medications, insulin, herbal substances, performing strenuous exercise or history of bariatric surgery. Fingerstick blood glucose readings revealed blood sugar of 35 mg/dL and 48 mg/dL, when she had these symptoms. Her medical history was significant for morbid obesity, hypothyroidism and gastro esophageal reflux disease. Her home medications included levothyroxine, propranolol and omeprazole. A blood sample obtained during the symptoms revealed the following: fingerstick blood sugar 38 mg/dL, venous blood glucose 60 mg/dL (normal (n): 70–99 mg/dL), serum insulin 202 IU/mL (n: <21), proinsulin 31.3 pmol/L (n: <28.9), C-peptide 8 ng/mL (n: 0.9–7), beta-hydroxybutyrate 0.12 mmol/L (n: 0.02–0.27) anti-insulin antibody >45.4 U/mL (n: <0.4). The result obtained while screening for serum sulfonylurea and meglitinides was negative. The repeated episodes of postprandial hypoglycemia associated with significantly elevated anti-insulin antibodies led to a diagnosis of insulin antibody syndrome (IAS). Significant improvement of hypoglycemic symptoms and lower anti-insulin antibody levels (33 U/mL) was noted on nutritional management during the following 6 months. Based on a report of pantoprazole-related IAS cases, her omeprazole was switched to a H2 receptor blocker. She reported only two episodes of hypoglycemia, and anti-insulin antibody levels were significantly lower at 10 U/mL after the following 12-month follow-up.Learning points:Initial assessment of the Whipple criteria is critical to establish the clinical diagnosis of hypoglycemia accurately.Blood sugar monitoring with fingerstick blood glucose method can provide important information during hypoglycemia workup.Autoimmune hypoglycemia is a rare cause of hypoglycemia, which can be diagnosed on high index of clinical suspicion and systematic evaluation.

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Section: Discussionmentioning

confidence: 99%

Section: Outcome and Follow-upmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Insulin Autoimmune Syndrome: a rare cause of postprandial hypoglycemia

Sahni

Trivedi

Omer

2016

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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“…The most common causes of hypoglycemia in non-diabetic patients are insulinoma, extra pancreatic tumors, and autoimmune hypoglycemia (1). The autoimmunity that causes hypoglycemia occurs in two ways: in-sulin receptor antibodies with insulin mimetic effects or insulin autoimmune syndrome characterized by insulin antibodies (1). The insulin autoimmune syndrome is characterized by spontaneous hypoglycemia, increased insulin levels, and increased circulating insulin antibodies, first described by Hirata et al in 1970 (2).…”

Section: Introductionmentioning

confidence: 99%

“…There are also publications showing association with other drugs, which most frequently include methimazole, along with others such as D-penicillamine, procainamide, isoniazid, hydralazine, glutathione, captopril, and imipenem (4). In addition, incidences related to alpha lipoic acid (5) and proton pump inhibitor (1,2) have also been reported.…”

Section: Introductionmentioning

confidence: 99%

Hypoglycemia Due to the Presence of Anti-insulin Antibodies: A Case Report

Alagüney¹,

Efe²,

Yorulmaz³

et al. 2019

Turk J Endocrinol Metab

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A 50-year-old male was referred to our clinic for hypoglycemic attacks. He denied using oral antidiabetic drugs, insulin, or herbal substances but admitted using proton pump inhibitors, pregabalin, and alpha lipoic acid. Venous blood glucose level was 44 mg/dL, C-peptide was 15.6 ng/mL, and insulin levels were >1.000 µIU/mL. His BMI was 21.4. No evidence of pancreatic or extra pancreatic insulinoma was found in imaging studies. No diagnostic results were obtained in the selective calcium receptor stimulation test. Anti-insulin antibody test was positive. The insulin autoimmune syndrome was diagnosed with low glucose levels. The symptoms were associated with very high serum insulin levels, and the patient was positive for the anti-insulin antibody. Alpha lipoic acid and proton pump inhibitors, which may cause insulin autoimmune syndrome, were discontinued and alpha glucosidase inhibitor and diet therapy were started. During follow-up, the patient did not report hypoglycemia. Insulin autoimmune hypoglycemia should be kept in mind in patients with very high levels of insulin and without evidence of insulinoma.

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