Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies
Objective: Insulin antibody (IA)-mediated insulin resistance (IR) is a rare condition for which immunosuppressive regimens have been described. However, these raise the risk of infection, and the drugs may not be effectively metabolized in patients with liver disease. A 61-year old male with type 2...
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| Format: | Article |
| Language: | English |
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Elsevier
2021-09-01
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| Series: | AACE Clinical Case Reports |
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| Online Access: | http://www.sciencedirect.com/science/article/pii/S2376060521000444 |
| _version_ | 1818695844257333248 |
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| author | Danielle Brooks, MD Priya Grewal, MD Ian Baine, MD, PhD Suzanne A. Arinsburg, DO Samir Maximos, MD Nirali A. Shah, MD |
| author_facet | Danielle Brooks, MD Priya Grewal, MD Ian Baine, MD, PhD Suzanne A. Arinsburg, DO Samir Maximos, MD Nirali A. Shah, MD |
| author_sort | Danielle Brooks, MD |
| collection | DOAJ |
| description | Objective: Insulin antibody (IA)-mediated insulin resistance (IR) is a rare condition for which immunosuppressive regimens have been described. However, these raise the risk of infection, and the drugs may not be effectively metabolized in patients with liver disease. A 61-year old male with type 2 diabetes mellitus and antibody-mediated IR who required >800 units of daily insulin presented with acute decompensation of his preexisting cirrhosis from recurrent diabetic ketoacidosis. Laboratory tests confirmed an IA level of >625 μU/mL (reference: <5.0 μU/mL). Methods: Centrifugal plasmapheresis and mycophenolate mofetil (MMF) were used to treat the patient to achieve glycemic control. Continuous glucose monitoring was implemented to monitor glycemic control pre- and posttherapy. Laboratory evaluation included levels of IA, C-peptide, insulin-like growth factor-1, growth hormone, salivary cortisol, zinc transporter 8, glutamic acid decarboxylase 65-kilodalton isoform antibody, and islet-cell antibodies. Results: We initiated MMF followed by 5 sessions of plasmapheresis, leading to an overall 77.3% reduction from pretherapy insulin requirements after 6 months without further episodes of diabetic ketoacidosis or infection. The cirrhosis stabilized, and there was an improvement in HbA1C from 8.7% (72 mmol/mol) to 6.6% (49 mmol/mol) and time in euglycemic range from 30% to 61%. Conclusion: This is the first report of MMF and centrifugal plasmapheresis use to mitigate the effects of IA-mediated IR in a patient with cirrhosis. We recommend further studies to determine the utility of this treatment to improve care for patients at high risk for IA-mediated IR. |
| first_indexed | 2024-12-17T13:51:56Z |
| format | Article |
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| institution | Directory Open Access Journal |
| issn | 2376-0605 |
| language | English |
| last_indexed | 2024-12-17T13:51:56Z |
| publishDate | 2021-09-01 |
| publisher | Elsevier |
| record_format | Article |
| series | AACE Clinical Case Reports |
| spelling | doaj.art-4530412b9d07422d98545aa5e3a49dad2022-12-21T21:46:01ZengElsevierAACE Clinical Case Reports2376-06052021-09-0175307309Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin AntibodiesDanielle Brooks, MD0Priya Grewal, MD1Ian Baine, MD, PhD2Suzanne A. Arinsburg, DO3Samir Maximos, MD4Nirali A. Shah, MD5Division of Endocrinology, Diabetes and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New YorkDivision of Liver Diseases and Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New YorkDepartment of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkDepartment of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkIndependent scholarDivision of Endocrinology, Diabetes and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York; Address author correspondence and reprint requested to Dr Nirali A. Shah, Division of Endocrinology, Diabetes and Metabolism, Assistant Professor of Medicine, 1 Gustave L. Levy Place, New York, NY 10029.Objective: Insulin antibody (IA)-mediated insulin resistance (IR) is a rare condition for which immunosuppressive regimens have been described. However, these raise the risk of infection, and the drugs may not be effectively metabolized in patients with liver disease. A 61-year old male with type 2 diabetes mellitus and antibody-mediated IR who required >800 units of daily insulin presented with acute decompensation of his preexisting cirrhosis from recurrent diabetic ketoacidosis. Laboratory tests confirmed an IA level of >625 μU/mL (reference: <5.0 μU/mL). Methods: Centrifugal plasmapheresis and mycophenolate mofetil (MMF) were used to treat the patient to achieve glycemic control. Continuous glucose monitoring was implemented to monitor glycemic control pre- and posttherapy. Laboratory evaluation included levels of IA, C-peptide, insulin-like growth factor-1, growth hormone, salivary cortisol, zinc transporter 8, glutamic acid decarboxylase 65-kilodalton isoform antibody, and islet-cell antibodies. Results: We initiated MMF followed by 5 sessions of plasmapheresis, leading to an overall 77.3% reduction from pretherapy insulin requirements after 6 months without further episodes of diabetic ketoacidosis or infection. The cirrhosis stabilized, and there was an improvement in HbA1C from 8.7% (72 mmol/mol) to 6.6% (49 mmol/mol) and time in euglycemic range from 30% to 61%. Conclusion: This is the first report of MMF and centrifugal plasmapheresis use to mitigate the effects of IA-mediated IR in a patient with cirrhosis. We recommend further studies to determine the utility of this treatment to improve care for patients at high risk for IA-mediated IR.http://www.sciencedirect.com/science/article/pii/S2376060521000444insulin antibodiesinsulin resistancemycophenolate mofetilplasmapheresistype 2 diabetes |
| spellingShingle | Danielle Brooks, MD Priya Grewal, MD Ian Baine, MD, PhD Suzanne A. Arinsburg, DO Samir Maximos, MD Nirali A. Shah, MD Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies AACE Clinical Case Reports insulin antibodies insulin resistance mycophenolate mofetil plasmapheresis type 2 diabetes |
| title | Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies |
| title_full | Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies |
| title_fullStr | Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies |
| title_full_unstemmed | Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies |
| title_short | Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies |
| title_sort | mycophenolate mofetil and plasmapheresis a treatment option for severe insulin resistance caused by insulin antibodies |
| topic | insulin antibodies insulin resistance mycophenolate mofetil plasmapheresis type 2 diabetes |
| url | http://www.sciencedirect.com/science/article/pii/S2376060521000444 |
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