Insulin Desensitization as an Effective Solution to Human Insulin Hypersensitivity and Its Associated Insulin Resistance
GE. Fouda1; GA. Badr2; HA. Khalil3; OE. Gharieb4; TI. Ali5; M. Darwish6; GE. Fouda7
1Allergy and Immunology Center, Al Azhar University, Cairo, Egypt; 2Professor of internal Medicine, Al Azhar University, Cairo, Egypt; 3Faculty of Biotechnology, October University for Modern Sciences and Arts , Cairo, Egypt, Egypt; 4Faculty of Applied Medical Science, 6 October University, Cairo, Egypt; 5Faculty of Biotechnology, October University of Modern Science and Arts, Cairo, Egypt; 6Department of Biotechnology, Faculty of Agriculture, Ein Shams University, Cairo, Egypt; 7Founder and director of the Allergy & Immunology Center, Al Azhar University, Cairo, Egypt
Case Report

Rationale: Insulin rapid drug desensitization (RDD) was decided for the purpose of managing insulin hypersensitivity and relieving diabetic ketoacidosis (DKA). We present a novel RDD protocol for insulin glargine (long-acting) and insulin glulisine (rapid-acting) performed on the same patient simultaneously and repeated several times. This is a rare case of an uncontrolled diabetic patient with type I hypersensitivity to most of the known human insulin analogues.

Methods: Our novel RDD protocol for insulin injections consists of 6 bags of dilutions, starting from dilution 1 with 50 IU glargine: 50 ml saline proceeding to dilution 6 (1: 5 million). The protocol consisted of 43 steps completed in 7 hours and 25 minutes using continuous subcutaneous insulin infusion (CSII) method and administering a total of 13.5 IU insulin. CSII was applied after failure of the traditional insulin subcutaneous injection method. Other different protocols were used for the preceding 3 days prior to this current protocol and have failed. After success of our current protocol, the patient was hospitalized 2 days for supervision and monitoring of random blood sugar (RBS) then discharged.

Results: The procedure was performed in the ICU of Al-Hussein University hospital, Al-Azhar University. RDD was 100% successful, with very mild breakthrough reactions (BTRs), mostly mild to moderate generalized pruritis that resolved spontaneously. While RDD was inducing tolerance to insulin, the insulin resistance gradually decreased and RBS gradually normalized. Prior to this RDD, the patient had shown an apparently relative resistance to insulin injections, where RBS was constantly very high not responding to insulin injections properly even while accompanied with pheniramine maleate injections. This successful protocol was performed efficiently in a few hours, unlike previous protocols which required 4-5 days. Success behind this protocol was due to starting with a very high dilution (1:5 Million) inducing rapid tolerance with very suboptimal allergenic doses.

Conclusion: To our knowledge, this is the first insulin rapid desensitization case in Egypt. Human insulin RDD using CSII is a safe and effective method to manage insulin hypersensitivity, DKA and abolish the associated insulin resistance. Insulin RDD is a very challenging procedure due to the restriction of using corticosteroids to control breakthrough reactions. Another challenge, is the elevation of RBS postprandial, urging the need for a full dose of insulin injection. Therefore, requiring short and efficient insulin RDD protocols.