Successful Management of Insulin Allergy and Autoimmune Polyendocrine Syndrome Type 4 with Desensitization Therapy and Glucocorticoid Treatment: A Case Report and Review of the Literature

Rojas, Joselyn; Villalobos, Marjorie; Martínez, María Sofía; Chávez-Castillo, Mervin; Torres, Wheeler; Mejías, José; Miquilena, Edgar; Bermúdez, Valmore

doi:10.1155/2014/394754

Cited by 8 publications

(12 citation statements)

References 43 publications

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“…For IgE-mediated reactions, a skin prick test and IgE antibody measurements are required. However, erythema developing at the injection site and induration are associated with IgG-mediated allergy and require measurement of anti-insulin IgG titers (9).…”

Section: Diagnosismentioning

confidence: 99%

“…Insulin allergy should be suspected in patients with nonspecific skin and systemic symptoms; these may be underlying symptoms of an autoimmune disease (9).…”

Section: Diagnosismentioning

confidence: 99%

“…Sometimes, new medication is not tolerated. The patient's condition becomes more serious, with deterioration in both allergic symptoms and glycemic regulation (9).…”

Section: Treatmentmentioning

confidence: 99%

“…When the symptoms and signs are related to the skin only, they may result from insulin hypersensitivity or may also be connected with irritation or other dermatologic conditions (prurigo simplex, atopic dermatitis, etc.) (9).…”

mentioning

confidence: 99%

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Insulin Allergy

Erdenen¹,

Kantarci²

2016

Istanbul Med J

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Insulin hypersensitivity reactions have been reported in both type 1 and type 2 diabetic patients. Some of these reactions stem from insulin itself, while some result from additive agents. Although reactions to all types of insulin can develop, reactions to human insulin and its analogues are rare. However, vital reactions can be observed. Previously used bovine and porcine insulins are known to be more immunogenic, and reactions to these types of insulin are more commonly observed. Due to the development of the purification process, the rate of these reactions has decreased considerably, from 30%-1% (1, 2). One-third of these reactions are associated with insulin, while the remaining reactions result from different substances that are added to the preparations. The allergic reaction types are named Type I, Type III, and Type IV (1-4). Skin reactions occurring at the injection site reduce the effects of exogenous insulin, stimulate insulin degradation, and/or impair insulin absorption. Thus, diabetes regulation also deteriorates (5).In addition to human insulins (NPH and regular insulins), analogues (lispro, aspart, glargine, detemir, glulisine, and degludec) may also induce allergic reactions. Stimulants may be an epitope of insulin itself and may also be changed by an antigenic epitope during production and purification. During subcutaneous degradation of insulin, different antigenic structures may be formed. Zinc and protamine are added to insulin to extend the duration of action, while metacresol and various contaminants are added as preservatives; these may cause reactions (1, 2). The commercially available insulin types and the additives they contain are presented in Table 1. Protamine is a cationic substance found in fish sperm; it is added to delay the release of insulin from the injection site. Exposure to protamine is a risk factor for allergy. Although fish allergies and vasectomy are believed to create risks in this regard, this situation was found to be only partly significant; no other relationships with other insulin types were observed, and no risk was found in a prospective study (3). However, protamine allergies and long-time use of insulin create risk for the production of insulin antibodies. In poorly controlled diabetes, this possibility should be considered. Although autoantibodies against protamine-heparin complex have been found, the relationship between insulin antibodies and protamine is not clear. This relationship is particularly significant in intermediate and rapid-acting insulins; the relationship between analogue insulins and autoantibodies was found to be contradictory. The time of insulin use, not the duration of diabetes, is significant. Protamine causes the formation of autoantibodies, probably by causing a change in the conformation of insulin. Also, cross-reactivity between human protamine and salmon protamine in insulin or the development of an immunologic response to salmon protamine can cause an allergic reaction. The amount of protamine found in NPH and insulin aspart is...

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Section: Diagnosismentioning

confidence: 99%

“…Insulin allergy should be suspected in patients with nonspecific skin and systemic symptoms; these may be underlying symptoms of an autoimmune disease (9).…”

Section: Diagnosismentioning

confidence: 99%

“…Sometimes, new medication is not tolerated. The patient's condition becomes more serious, with deterioration in both allergic symptoms and glycemic regulation (9).…”

Section: Treatmentmentioning

confidence: 99%

mentioning

confidence: 99%

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Insulin Allergy

Erdenen¹,

Kantarci²

2016

Istanbul Med J

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“…There have been previous reports of negative prick test results using insulin glargine in insulin-allergic patients. This can be attributed either to the smaller proportion of free insulin due to complexation of insulin glargine or, alternatively, to its lower allergenic potential [ 5 ] .…”

mentioning

confidence: 99%

Diagnosis and treatment of IgE‐mediated insulin hypersensitivity: two case reports

Belge

Fischer

Glatthaar

et al. 2019

J Deutsche Derma Gesell

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Faulty Injection Technique: A Preventable But Often Overlooked Factor in Insulin Allergy

2016

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Insulin hypersensitivity—a rare occurrence with currently available insulin preparations—may have varied manifestations, ranging from a local injection site allergy to severe generalized anaphylactic reactions. While various additives included in commercial insulin preparations and insulin peptides themselves remain the primary allergens responsible, faulty injection technique may at times potentiate the development of insulin allergy. Management of insulin allergy is complex, potentially dangerous at times, and can be challenging for the treating physician. We report a case of insulin allergy due to intradermal insulin injections which was cured by adopting a proper injection technique.

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Successful Management of Insulin Allergy and Autoimmune Polyendocrine Syndrome Type 4 with Desensitization Therapy and Glucocorticoid Treatment: A Case Report and Review of the Literature

Cited by 8 publications

References 43 publications

Insulin Allergy

Insulin Allergy

Diagnosis and treatment of IgE‐mediated insulin hypersensitivity: two case reports

Faulty Injection Technique: A Preventable But Often Overlooked Factor in Insulin Allergy

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