Rapid Desensitization with Intravenous Insulin in a Patient with Diabetic Ketoacidosis and Insulin Allergy

Abstract

<jats:sec><jats:title>Objective:</jats:title><jats:p> We report a case of insulin desensitization in a patient with known allergy to multiple insulin preparations who presented with diabetic ketoacidosis (DKA). </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> Clinical and laboratory data, and desensitization protocols are presented. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> A 65-year-old woman with type 2 diabetes and a documented insulin allergy presented with severe DKA. She was managed initially with intravenous (IV) fluids, sodium bicarbonate, and hemodialysis. An intradermal skin test was positive for 0.01 units/mL of human regular insulin. A rapid desensitization protocol for IV human regular insulin was initiated after pretreatment with methylprednisolone, ranitidine, montelukast, and cetirizine. An initial dilution of 1 unit of insulin in 100,000 mL of 0.9% sodium chloride was started at 5 mL/hour IV. The dilution was increased at 60-minute intervals to 1 unit/10,000 mL, 1 unit/1,000 mL, 1 unit/100 mL, 1 unit/10 mL, then 1 unit/1 mL. The dose was then increased from 1 to 7 units/hour (0.1 units/kg body weight/hour). The anion gap closed after 24 hours, and overlapping desensitization was started for subcutaneous (SC) human regular insulin starting with 0.00001 units with a gradual increase to 7 units before meals and 6 units at bedtime over 5 days. There were no anaphylactic reactions to IV or SC insulin. She was discharged with human regular insulin SC 4 times daily, oral montelukast, cetirizine, diphenhydramine as needed, and an epinephrine pen. No allergic reactions were reported at follow-up visits. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Rapid insulin desensitization is possible to allow treatment of DKA with human regular insulin IV in patients with known insulin allergy. </jats:p></jats:sec>

Prerequisite of Insulin and Intravenous Fluid in the Treatment of Diabetic Ketoacidosis to Overwhelmed the Catastrophe

“…Patients were found to have a longer duration of ketonuria compared to biochemical and clinical enhancement as demonstrated by HCO3 and pH levels. A comparable opinion was conveyed very recently in one Indian study [19][20] . Correction of acidosis in the majority of patients (24%) took 48 hours, up to a maximum of 1-week.…”

Skin tests in the work‐up of cutaneous adverse drug reactions: A review and update

“…29 IDTs with insulins are tested at a concentration of 1:10. 57,58 IDTs with platinum salts are specific for immediate readings with dilutions from 0.1 to 1 mg/mL, depending on the salt; 59,60 however, non-specific erythematous infiltration can occur after 24 hours with these IDT dilutions. These delayed reactions appear to be non-specific, as was reported regarding carboplatin at 1 mg/mL, 61 and as has been observed with oxaliplatin (A. Barbaud, unpublished data).…”

Utilizing Biologics in Drug Desensitization

“…Rapid desensitization to insulin with premedication and administration of progressively increasing doses of the desired type of insulin has been successfully performed [ 67 , 69 ]. Even a patient who presented with diabetic ketoacidosis requiring urgent hemodialysis to correct severe metabolic acidosis experienced a successful rapid desensitization to insulin, transitioning from intravenous insulin to subcutaneous insulin over a course of days [ 70 ].…”