Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies

Danielle Brooks; Priya Grewal; Ian Baine; Suzanne A Arinsburg; Samir Maximos; Nirali A Shah

doi:10.1016/j.aace.2021.03.004

Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies

AACE Clin Case Rep. 2021 Mar 13;7(5):307-309. doi: 10.1016/j.aace.2021.03.004. eCollection 2021 Sep-Oct.

Authors

Danielle Brooks¹, Priya Grewal², Ian Baine³, Suzanne A Arinsburg³, Samir Maximos⁴, Nirali A Shah¹

Affiliations

¹ Division of Endocrinology, Diabetes and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York.
² Division of Liver Diseases and Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
³ Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
⁴ Independent scholar.

Abstract

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.

Keywords: CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; FSG, fingerstick glucose; IA, insulin antibody; IR, insulin resistance; MELD, Model for End-Stage Liver Disease; MMF, mycophenolate mofetil; T2DM, type 2 diabetes mellitus; TDD, total daily dose; U-500, concentrated human regular insulin 500 U/mL; insulin antibodies; insulin resistance; mycophenolate mofetil; plasmapheresis; type 2 diabetes.

Publication types

Case Reports