scholarly journals RAPID DESENSITIZATION WITH INTRAVENOUS INSULIN IN A PATIENT WITH DIABETIC KETOACIDOSIS AND INSULIN ALLERGY

2020 ◽  
Vol 6 (4) ◽  
pp. e147-e150
Author(s):  
Shirley Shuster ◽  
Rozita Borici-Mazi ◽  
Sara Awad ◽  
Robyn L. Houlden
Keyword(s):  
Diabetic Ketoacidosis ◽  
Gradual Increase ◽  
Laboratory Data ◽  
Regular Insulin ◽  
Initial Dilution ◽  
Insulin Allergy ◽  
Intravenous Insulin ◽  
Desensitization Protocol

Objective: We report a case of insulin desensitization in a patient with known allergy to multiple insulin preparations who presented with diabetic ketoacidosis (DKA). Methods: Clinical and laboratory data, and desensitization protocols are presented. Results: 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. Conclusion: Rapid insulin desensitization is possible to allow treatment of DKA with human regular insulin IV in patients with known insulin allergy.

Hyperglycaemic crisis secondary to emphysematous pyelonephritis

2021 ◽  
Vol 14 (8) ◽  
pp. e242617
Author(s):  
Katie Liston ◽  
Rustom P Manecksha ◽  
Conor P Woods
Keyword(s):  
Kidney Injury ◽  
Glycated Haemoglobin ◽  
Generation Cephalosporin ◽  
Rare Presentation ◽  
Emphysematous Pyelonephritis ◽  
Intravenous Insulin ◽  
Intravenous Antibiotics ◽  
New Diagnosis

A 49-year-old woman presented to the emergency department acutely unwell. Initial investigations revealed hyperglycaemia, ketosis and an acute kidney injury precipitated by urosepsis. She was found to have a new diagnosis of diabetes mellitus (type 2) with a glycated haemoglobin (HbA1c) of 156 mmol/mol. CT imaging of the abdomen and pelvis revealed unilateral emphysematous pyelonephritis (EPN), radiologically classified as stage 3 severity with gas extending beyond the renal collecting system. Escherichia coli was grown on blood and urine cultures. This was sensitive to second-generation cephalosporin cefuroxime. The patient was managed with fluid resuscitation, intravenous antibiotics and renal system decompression with urinary catheter insertion. She was commenced on an intravenous insulin infusion for hyperglycaemic crisis. This case illustrates a rare presentation of hyperglycaemic crisis precipitated by EPN in a patient without a previously known diagnosis of diabetes, successfully treated with medical management alone. Close clinical and radiological follow-up was arranged to monitor the need for future nephrectomy.

scholarly journals Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus

2021 ◽  
Vol 14 (8) ◽  
pp. e243696
Author(s):  
Timothy Xin Zhong Tan ◽  
Steven Hoon Chin Lim ◽  
Joan Khoo
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Diabetic Ketoacidosis ◽  
Good Effect ◽  
Lifestyle Modifications ◽  
Diagnostic Challenge ◽  
Intravenous Insulin ◽  
One Year

A 54-year-old woman with insulin-requiring type 2 diabetes mellitus presented with acute shortness of breath and drowsiness on a background of polydipsia, weakness and significant weight loss. One year ago, she had decided to stop her insulin and other medications and adopt lifestyle modifications instead. Initial emergency department (ED) blood samples were highly lipaemic and appeared strawberry pink. She was eventually diagnosed with diabetic ketoacidosis (DKA) with severe hypertriglyceridaemia, intubated for airway protection, and managed with fluid resuscitation and intravenous insulin to good effect. We share an uncommon DKA presentation at the ED. History was limited as the patient was drowsy and minimally communicative. Physical examination was unremarkable. Blood investigations were also delayed in view of the need for additional centrifugation. These contributed to a paucity of information in the acute setting and resulted in a diagnostic challenge.

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 Diabetic ketoacidosis: Should current management include subcutaneous insulin injections?

2017 ◽  
Vol 5 (19) ◽  
pp. 6
Author(s):  
Rocio Gavidia Quezada ◽  
Hawa Edriss
Keyword(s):  
Intensive Care ◽  
Diabetic Ketoacidosis ◽  
Insulin Analogues ◽  
Subcutaneous Insulin ◽  
Acute Complication ◽  
Intravenous Insulin ◽  
Number Of Patients ◽  
Electrolyte Abnormalities

Diabetic ketoacidosis is a well-known acute complication in patients with both type 1 andtype 2 diabetes mellitus. Although mortality has decreased considerably, it remains an importantcause for admission to intensive care units. Medical management includes intravenous fluidtherapy, insulin, correction of electrolyte abnormalities, and addressing the precipitating factorwhich in most cases is infection or non-compliance with insulin therapy. Usually patients withdiabetic ketoacidosis are admitted to the intensive care unit for continuous infusion of insulin;however, the development of rapid acting insulin analogues has made it possible to treatmild to moderate diabetic ketoacidosis with subcutaneous insulin. Although studies usingsubcutaneous insulin include only a small number of patients, this approach seems as effectiveas intravenous insulin infusions in patients with mild to moderate diabetic ketoacidosis. Diabeticeducation and close follow-up for patients admitted for diabetic ketoacidosis remain essentialto avoid recurrence and readmissions.Keywords: Diabetic ketoacidosis, acute complication in diabetes, rapid acting insulinanalogues, subcutaneous insulin in diabetic ketoacidosis

Treatment of Diabetic Ketoacidosis With Intravenous U-500 Insulin in a Patient With Rabson-Mendenhall Syndrome: A Case Report

2016 ◽  
Vol 30 (4) ◽  
pp. 468-475 ◽  
Author(s):  
Megan M. Moore ◽  
Abby M. Bailey ◽  
Alexander H. Flannery ◽  
Regan A. Baum
Keyword(s):  
Insulin Resistance ◽  
Case Report ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Genetic Disorder ◽  
Regular Insulin ◽  
Control Blood Glucose ◽  
Intravenous Insulin ◽  
High Doses

Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.

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 A Case of Concomitant COVID-19 Infection-Induced Acute Respiratory Distress Syndrome and Diabetic Ketoacidosis: Another Challenge in Fluid Management

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A357-A357
Author(s):  
Panadeekarn Panjawatanan ◽  
Samir Jha ◽  
Joseph Hughes ◽  
Erik Riesenfeld
Keyword(s):  
Type 2 Diabetes ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Diabetic Ketoacidosis ◽  
Distress Syndrome ◽  
Insulin Degludec ◽  
Intravenous Insulin ◽  
Sliding Scale

Abstract Background: Coronavirus Disease 2019 (COVID-19) has been announced as a pandemic worldwide. The respiratory tract is a target organ-system which can result in serious complications like acute respiratory distress syndrome (ARDS). Management of this condition is more challenging in diabetes who developed diabetic ketoacidosis (DKA). Clinical Case: We report a case of a 59-year-old male who presented with 4 days of productive cough with blood-tinged sputum, shortness of breath, and chills. Patient had decreased oral intake and had not been compliant with his medication. He had underlying disease significant for type 2 diabetes, essential hypertension, obesity (BMI 32 kg/m2), history of pancreatitis and diabetic ketoacidosis. His diabetes medications included insulin degludec 126 units with insulin lispro sliding scale, dulaglutide, metformin, and sitagliptin. On examination, the patient was lethargic. Initial vital signs included a temperature of 36.8°C, respiratory rate 24/min, heart rate 65 bpm, BP 140/67 mmHg, and oxygen saturation 91% on room air. Lung auscultation revealed bilateral widespread crackles. Laboratory was significant for glucose 387 mg/dL (70–139), pH 7.25 (7.35-7.28), anion gap 15.8 mEq/L (6–14) and concurrent normal gap acidosis, urine ketones 15 mg/dL (negative), and LDH 325 U/L (140–171). An initial chest x-ray showed bilateral peripheral pulmonary infiltrates. Workup was negative for influenza, pneumococcus, and legionella. The patient was subsequently intubated on the first day for worsening hypoxia due to severe ARDS (PaO2/FiO2 ratio of 71). He was concomitantly treated for DKA and hypotension with intravenous insulin, initially started at 12 units/hour with subsequent titration down to average of 5 units/hour, fluid resuscitation (approximate 34 ml/kg actual body weight) and, potassium repletion on the first day. On the same day, his hypoxia worsened with an increase in pulmonary infiltrates, so we stopped intravenous fluids and initiated norepinephrine for 24 hours. His mechanical ventilation settings followed ARDS guidelines. Positive COVID-19 was detected from real-time RT-PCR. After maintaining a negative fluid balance, we were able to extubate in 72 hours. Intravenous insulin was continued for 46 hours then was switched to subcutaneous basal-bolus regimen. He was discharged with insulin degludec 100 units with insulin lispro sliding scale, metformin, and sitagliptin. Dulaglutide was held. Conclusion: Type 2 diabetes are rarely affected by DKA but can be found in up to 27% of the cases. There are reports of ARDS as a serious complication in severe DKA in adults and children, yet no data for concomitant DKA and ARDS has been published. We propose that the management of DKA in COVID-19 patients with ARDS may be similar to the paradigm utilized for other volume restriction in patients with congestive heart failure and end-stage renal failure.

Morbidity and Mortality Later Than 2 Years After HSCT. A Sinle Institution Experience.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 4508-4508
Author(s):  
Hideki Akiyama ◽  
Wataru Munakata ◽  
Takeshi Kobayashi ◽  
Kazuhiko Kakihana ◽  
Takuya Yamashita ◽  
...  
Keyword(s):  
Conflicts Of Interest ◽  
Chronic Gvhd ◽  
Laboratory Data ◽  
Regular Insulin ◽  
Pulmonary Complications ◽  
Secondary Malignancy ◽  
Hematopoietic Stem ◽  
Renal Complication ◽  
Long Term Follow Up

Abstract Abstract 4508 Long-term follow-up data of the patients who underwent HSCT more than 2 years ago at a single institution in Japan was presented. The patients who received first allogeneic hematopoietic stem cell transplantation (HSCT) at Tokyo Metropolitan Komagome Hospital between January, 1990 and December, 2007 under hematology division were included. Follow-up data were obtained annually from the medical records if the patients visited our institution regularly. If the patients were not followed in our institution, follow-up data were requested to the hospitals where the patients had been followed or questionnaires were sent directly to the patients unless their addresses are not known. These letters were sent annually. The most recent laboratory data and any kind of complications under treatment including hypertension, hyperlipidemia, diabetes including usage of insulin, renal failure, dialysis, and any kind of malignancies were requested to be reported. Survival was the most primitive data and the reason of death was defined by one of the authors, HA. Chronic GVHD was excluded from the independent etiology of death. Progression of the disease or complications of the treatment for the progressive disease were considered to be due to relapse. The incidence of each complication was calculated using the number of the patients whose data are available. In total, 622 patients had received transplantation and 370 patients survived more than 2 years. During last two years, 211 patients had been followed in our institution while 74 patients by the institutions outside. Letters were sent directly to rest of surviving patients. As the result, 6 patients could not be reached by any method. Letters had been received without response in 15 patients. 72 patients died later than 2 years after transplantation. Relapse was the most important reason of death even more than 2 years after the transplantation. Although the incidence declined annually, the latest relapse was observed in the patient with CML almost 15 years after the transplantation. Pulmonary complications including bronchiolitis obliterans and infections followed. Secondary malignancy was the reason of death in 7 patients. Chronic kidney disease was already observed in 27 % of the patients who survived 2 years after transplantation and one of the devastating complications. In total of 7 patients needed to start regular dialysis or kidney transplantation and another 2 patients showed eGFR level of less than 15 ml/min/m2. Nephrotic syndrome was another renal complication observed in 4 patients. Hypertension was reported on 46/244 (19%) of the patients. Diabetes was reported on 27/241 (11.2%) and 13 of them were on regular insulin treatment. Definitive diagnostic criteria of diabetes were not indicated on this analysis suggesting higher incidence of glucose intolerance in these patients. There were 14 patients developed secondary malignancies diagnosed later than 2 years after transplantation and oral mucosa, tongue, esophagus and colon were the main organs involved. Physicians taking care of those patients were recommended to check kidney function and gastrointestinal tract including head/neck, esophagus and colon for secondary malignancy, as well as hematological status. Disclosures: No relevant conflicts of interest to declare.

Success rate and myeloid toxicity of carboplatin desensitization protocol in low grade glioma patients

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 20012-20012
Author(s):  
S. Berrak ◽  
D. B. Beker ◽  
C. Canpolat ◽  
F. B. Cakir
Keyword(s):  
Febrile Neutropenia ◽  
Success Rate ◽  
Gradual Increase ◽  
Median Number ◽  
Low Grade Glioma ◽  
Low Grade ◽  
Hypersensitivity Reactions ◽  
Glial Tumors ◽  
Desensitization Protocol

20012 The effectiveness of carboplatin and vincristine chemotherapy in the treatment of low grade glial tumors is well established. This study was retrospectively designed to investigate the success rate and myeloid toxicity of carboplatin desensitization in a group of patients with carboplatin allergy. A total of 45 patients followed between October 1998-January 2007 with low grade glial tumors were included into study. Patients with severe hypersensitivity reactions (including anaphylaxis) were given 6-step desensitization protocol with gradual increase in concentration of carboplatin over 6 hours. Weekly absolute neutrophil count (ANC) and number of febrile neutropenia episodes of each patient during treatment period were collected from patient files. Among 45 patients, eight were switched to desensitization protocol. They had received a median of 6 courses (range 1–29) of carboplatin before developing their first allergic reaction. A median number of 15 courses of desensitizations (range 3–40) were given to these patients. Desensitization was successful in 6 patients. Age, gender, diagnosis were found to be similar in patients with and without carboplatin allergy. Regarding myeloid toxicity, mean percentage of follow-up weeks with ANC values below 1,500/mm3 in patients with and without desensitization were 0.42±0.04 and 0.21±0.02, respectively (p=0.009). Mean percentage of weeks with ANC values below 500/mm3 were not significant between two groups (p=0.28). However, desensitization protocol was not found to have an impact on number and presence of febrile neutropenia episodes. In conclusion, desensitization protocol might be an alternative to complete scheduled treatment in low grade glioma patients with hypersensitivity to carboplatin. Although, the percentage of low ANC weeks seemed to be statistically higher, insignificance of febrile neutopenia episodes in our patients demonstrated safety of desensitization protocol in terms of myeloid toxicity. No significant financial relationships to disclose.

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