Combined Immunosuppressive Therapy Induces Remission in Patients With Severe Type B Insulin Resistance: A Prospective Cohort Study

Joanna Klubo-Gwiezdzinska, Maria Lange, Elaine Cochran, Robert K Semple, Cornelia Gewert, Rebecca J Brown, Phillip Gorden, Joanna Klubo-Gwiezdzinska, Maria Lange, Elaine Cochran, Robert K Semple, Cornelia Gewert, Rebecca J Brown, Phillip Gorden

Abstract

Objective: Type B insulin resistance due to autoantibodies against the insulin receptor is characterized by diabetes refractory to massive doses of insulin, severe hypercatabolism, hyperandrogenism, and a high mortality rate. We analyzed the efficacy of combined immunosuppressive therapy in the management of this extreme form of diabetes.

Research design and methods: We performed a prospective cohort study including patients with confirmed insulin receptor autoantibodies, monitored for median 72 months (25th, 75th interquartile range 25, 88), and treated with rituximab, high-dose pulsed steroids, and cyclophosphamide until remission, followed by maintenance therapy with azathioprine. Remission was defined as the amelioration of the hyperglycemia and discontinuation of insulin and/or normalization of hyperandrogenemia.

Results: All data are given as median (25th, 75th interquartile range). Twenty-two patients aged 42 (25, 57) years, 86.4% women, fulfilled inclusion criteria. At baseline, fasting glucose was 307 (203, 398) mg/dL, HbA1c was 11.8% (9.7, 13.6), total testosterone (women) was 126 (57, 571) ng/dL (normal 8-60), and daily insulin requirement was 1,775 (863, 2,700) units. After 5 (4, 6.3) months, 86.4% (19 of 22) of patients achieved remission, documented by discontinuation of insulin in all patients, normal fasting glucose of 80 (76, 92) mg/dL, HbA1c of 5.5% (5.2, 6), and testosterone (women) of 28 (20, 47) ng/dL. During follow-up of 72 (25, 88) months, 13.6% (3 of 22) of patients developed disease recurrence, occurring 24 (22, 36) months after initial remission, which responded to repeated therapy. None of the patients died.

Conclusions: Combined immunosuppressive therapy has changed the natural history of this disease, from 54% mortality to a curable form of diabetes and, as such, should be recommended in patients with type B insulin resistance.

Trial registration: ClinicalTrials.gov NCT00001987.

© 2018 by the American Diabetes Association.

Figures

Figure 1
Figure 1
Summary of the management of type B insulin resistance. *The diagram includes the most common adverse side effects, but the spectrum of side effects is not limited to the ones listed. BSA, body surface area; CBC, complete blood count; TB, tuberculosis.
Figure 2
Figure 2
Resolution of acanthosis nigricans after the combined targeted immunosuppressive therapy.

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