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Treatment Approach to Patients with Severe Insulin Resistance Timothy J

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Treatment Approach to Patients with Severe Insulin Resistance Timothy J Treatment Approach to Patients With Severe Insulin Resistance Timothy J. Church1 and Stuart T. Haines2 FEATURE ARTICLE FEATURE ■ IN BRIEF Patients with severe insulin resistance require >2 units/kg of body weight or 200 units/day of insulin. Yet, many patients do not achieve glycemic targets despite using very high doses of insulin. Insulin can cause weight gain, which further contributes to worsening insulin resistance. This article describes the pharmacological options for managing patients with severe insulin resistance, including the use of U-500 insulin and newer agents in combination with insulin. n increasing number of pa- require >1 unit/kg/day are considered tients have severe insulin resis- to have insulin resistance, and those Atance and require large doses requiring >2 units/kg/day have severe of insulin. Managing patients with resistance (3). Alternatively, a total severe insulin resistance is challenging daily insulin dose of >200 units is because it is difficult to achieve good commonly considered to be evidence glycemic control using conventional of severe insulin resistance. Large total treatment approaches (1). Moreover, daily dose requirements create practi- weight gain, hypoglycemia, regimen cal problems with regard to insulin complexity, and cost are frequent con- delivery because 1) a large volume of cerns as insulin doses escalate. standard U-100 insulin can be pain- Insulin resistance is characterized ful to administer and 2) the onset and by an impaired response to either duration of insulin activity can be endogenous or exogenous insulin (2). altered with high-volume doses (4). Although insulin resistance is a com- Evaluating Patients mon feature of type 2 diabetes, cases There are several known causes of of severe insulin resistance remain severe insulin resistance, including relatively uncommon but are likely several rare disorders and genet- increasing as the prevalence of dia- ic conditions (Table 1) (3). Several betes and obesity surges. The degree medications are known to contribute 1West Palm Beach Veteran’s Administration of insulin resistance can be measured Medical Center, West Palm Beach, FL to insulin resistance, including gluco- using the euglyemic insulin clamp corticoids, protease inhibitors, atyp- 2University of Maryland School of Pharmacy, Department of Pharmacy Practice and technique, but this is not a clinically ical antipsychotics, and calcineurin Science, Baltimore, MD useful method of determining whether inhibitors. In patients with severe Corresponding author: Stuart T. Haines, a patient has severe insulin resistance insulin resistance, an effort should be [email protected] in practice (3). The most widely made to discontinue such agents or DOI: 10.2337/diaclin.34.2.97 reported and clinically useful defini- switch to alternative medications if tions of severe insulin resistance are possible (5). ©2016 by the American Diabetes Association. Readers may use this article as long as the work based on exogenous insulin require- Poor medication-taking behaviors is properly cited, the use is educational and not ments using either the number of units or “pseudoresistance” should be ruled for profit, and the work is not altered. See http:// creativecommons.org/licenses/by-nc-nd/3.0 per kilogram of body weight per day out before modifying or intensifying for details. or the total daily dose (1). Patients who therapy. Pseudoresistance may be the VOLUME 34, NUMBER 2, SPRING 2016 97 FEATURE ARTICLE TABLE 1. Causes of Severe equal to what an average person with and clinical trials comparing these Insulin Resistance (3) diabetes might require (insulin dose products to U-500 insulin have not [units] = blood glucose [mg/dL] – 100 been conducted. Although they are Syndromes of severe insulin × resistance / (1,500 / weight [kg] 1.0)] should two to three times more concentrated • Type A, due to defects in the be given. If there is not an appropri- than U-100 insulin, U-300 insulin insulin receptor gene ate drop in blood glucose within 4 glargine and U-200 insulin lispro can • Type B, due to insulin receptor hours, a second dose should be given. only deliver a maximum of 80 and antibodies If normoglycemia or hypoglycemia 60 units per injection, respectively. • Type C, cause unknown is not achieved after either dose, the They do offer the theoretical advan- (also known as HAIR-AN test confirms that a patient likely has tage of providing a dose of insulin in [Hyperandrogenism, Insulin severe insulin resistance. a smaller injection volume than would Resistance, and Acanthosis Nigricans] syndrome) Pharmacological Treatment be required with U-100 (8,9). Similar to U-100 regular insulin, Medications Options the onset of activity for U-500 regular • Glucocorticoids There are currently no guidelines or insulin is ~30–45 minutes. However, • Atypical antipsychotics consensus statements describing how the time to peak activity (4–6 hours) • Calcineurin inhibitors best to treat patients with severe in- and duration of action (12–14 hours) • Protease inhibitors sulin resistance. Until recently, insu- for U-500 is most similar to NPH • Oral contraceptives lin was the only therapy available to insulin (6). treat those with severe insulin resis- Endocrine disorders In several crossover studies in tance. Despite the use of high doses • Acromegaly which patients with severe insulin of insulin, however, many patients • Glucagonoma resistance were switched from U-100 do not reach their glycemic targets • Thyrotoxicosis insulin products to U-500 regular • Cushing’s syndrome and are hampered by undesirable insulin, significant improvements in • Pheochromocytoma adverse effects such as hypoglycemia glycemic control have been observed and weight gain. To mitigate some of Anti-insulin antibodies (10–18). An analysis of nine studies these challenges, several new thera- HIV-associated lipodystrophy (n = 310 patients) found that U-500 pies have emerged and can be used in reduced mean A1C by 1.59% (95% CI Physiological causes combination with insulin. • Severe stress 1.26–1.92) in patients who previously ❍ Trauma Concentrated Insulin Products used a multiple daily injection (MDI) ❍ Sepsis Concentrated insulin products can regimen with various U-100 insulin ❍ Surgery help improve the delivery of insulin products. At baseline, these patients ❍ Diabetic ketoacidosis when very large doses are needed. had an A1C between 9.1 and 11.3% • Pregnancy U-500 insulin is five times more con- and a total daily insulin requirement • Puberty centrated than standard U-100 insu- of 219–391 units. They were followed Pseudoresistance lin and is considered the cornerstone for 6–36 months. Weight gain was • Poor administration technique of therapy for most patients with se- a substantial problem, with a mean • Incorrect storage of insulin vere insulin resistance (6). When dai- increase of 4.4 kg (95% CI 2.4–6.4) • Malingering for secondary gain ly insulin doses exceed 200 units/day, in body weight. The mean total daily the volume of U-100 insulin needed insulin dose increased by 52 units makes insulin delivery challenging. (95% CI 20–84) (19). U-500 insulin result of nonadherence, poor injec- Available insulin syringes can deliver delivered by continuous subcutaneous tion technique, improper insulin a maximum of 100 units, and insulin insulin infusion (CSII) is a potential storage, or malingering for secondary pen devices can deliver only 60–80 option. In one study, U-500 delivered gain. Pseudoresistance can be ruled units per injection. In addition, the via CSII reduced mean A1C by 1.1% out by conducting a modified insu- administration of doses >1 mL in (P = 0.026) in a cohort of patients lin tolerance test (3). During such a volume can be painful and may alter with severe insulin resistance who test, patients are administered a wit- insulin absorption (7). were switched from a variety of insu- nessed dose of short-acting insulin Two new concentrated insulin lin regimens, including U-500 insulin in the clinic, and their blood glucose pen products are now available in the via MDI (20). is monitored every 30 minutes for a United States—U-200 insulin lispro The risk of severe hypoglycemia period of 4–8 hours. Patients should and U-300 insulin glargine. There is does not appear to increase when be fasting for the test and should have no reported experience using these patients are switched from U-100 to a blood glucose level >150 mg/dL. A new concentrated insulin products in U-500 insulin (6,19). However, some witnessed insulin dose approximately patients with severe insulin resistance, studies have reported an increase in 98 CLINICAL.DIABETESJOURNALS.ORG CHURCH AND HAINES mild hypoglycemic events, defined meal. One of the biggest drawbacks tial pharmacological option for most as symptomatic episodes that did not to using U-500 insulin is the poten- people with type 2 diabetes. It has a require assistance (13,15). One retro- tial for dosing errors that can lead to strong record of safety and efficacy, spective study reported an increase severe hypoglycemia, coma, or death. as well as a favorable effect on weight in the frequency of mild hypoglyce- Clear communications between the (22). Although it is common practice mic episodes only during the first 3 prescriber, pharmacist, and patient to combine metformin with insulin, months after transitioning to U-500 are crucial. When prescribing and metformin use has not been specifi- insulin (13). dispensing U-500 regular insulin, cally evaluated in the setting of severe When transitioning a patient the dose should be expressed in both insulin resistance. from U-100 to U-500 insulin, the units and volume (mL) to be adminis- In most studies of U-500 regular insulin, patients have been permitted dose and dosing frequency should tered. To minimize the risk of errors, to continue metformin use (6,23,24). be determined based on the patient’s a 0.5–1 mL tuberculin syringe with a In patients who do not have severe current A1C and total daily insulin 29-gauge or higher needle should be insulin resistance, metformin use ARTICLE FEATURE dose.
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