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

Abstract

Management of type 1 diabetes in patients who have insulin hypersensitivity is a clinical challenge and places patients at risk for recurrent diabetic ketoacidosis (DKA). Hypersensitivity reactions can be due to the patient's response to the insulin molecule itself or one of the injection's non-insulin components. It is therefore crucial for clinicians to quickly recognize the type of hypersensitivity reaction that is occurring and identify potentially immunogenic additives for the purpose of directing therapy as various insulin preparations have differing ingredients. We present the case of a 23-year-old diabetic female with common variable immunodeficiency (CVID) and autoimmune enteropathy who developed a type III hypersensitivity reaction to multiple formulations of subcutaneous insulin after years of use and the challenges of devising a long-term management strategy.

Ambulatory intravenous insulin and islet cell transplantation to treat severe type III insulin hypersensitivity in a patient with type 1 diabetes mellitus

“…This can contribute to prolonged hospitalization. 5 Ambulatory IVI has been reported in a single case of T1HS to subcutaneous insulin, 8 though our patient marks the first reported use for severe T3HS. IVI use was considered justified in our patient in spite of potential risks given the absence of reasonable alternative strategies and the significant morbidity attributable to the hypersensitivity reaction.…”

“…IVI may help to control glycemia in difficult cases of insulin hypersensitivity, but the use is typically confined to the hospital setting, due to issues including securing intravenous access, monitoring, and safety. This can contribute to prolonged hospitalization 5 . Ambulatory IVI has been reported in a single case of T1HS to subcutaneous insulin, 8 though our patient marks the first reported use for severe T3HS.…”

“…Desensitization, though efficacious for IgE mediated, immediate type-1 hypersensitivity (T1HS), 3,5 has been noted to be unsuccessful in other cases of T3HS. 5,6 Oral prednisolone doses up to 40 mg daily 5 have been reported as efficacious, but the use is typically described in conjunction with other interventions, such as insulin cessation, 7 change, or use of an alternate immunosuppressant. 5 Our patient received a relatively low prednisolone dose (10 mg daily), which may explain the absence of response to glucocorticoids.…”

“…4 In our patient, standard treatment measures were ineffective. Desensitization, though efficacious for IgE mediated, immediate type-1 hypersensitivity (T1HS), 3,5 has been noted to be unsuccessful in other cases of T3HS. 5,6 Oral prednisolone doses up to 40 mg daily 5 have been reported as efficacious, but the use is typically described in conjunction with other interventions, such as insulin cessation, 7 change, or use of an alternate immunosuppressant.…”

“…5,6 Oral prednisolone doses up to 40 mg daily 5 have been reported as efficacious, but the use is typically described in conjunction with other interventions, such as insulin cessation, 7 change, or use of an alternate immunosuppressant. 5 Our patient received a relatively low prednisolone dose (10 mg daily), which may explain the absence of response to glucocorticoids. Adjunctive strategies as above were nonetheless either unsuccessful or inappropriate to implement in this case, and the hyperglycemic effects of glucocorticoids remain problematic for their utility as long-term treatment.…”