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Question:

From Virginia, USA:

After 2 years of terrible control on insulin shots, the endocrinologist hypothesized that my 4 year old son has skin antibodies to insulin, so he placed him on the insulin pump to keep the antibody receptor sites saturated so the rest of the insulin could be absorbed. It has worked beautifully and his A1Cs have gone from 12 to 7. I'm a physician myself and have been unable to find anything in the literature about skin antibodies to insulin. Can you comment on this? Also, my son also has vitiligo; could this somehow be connected?

Answer:

To deal with your second question first, vitiligo has long been recognised as a condition associated with diabetes. Only in more recent times however has it been defined as an autoimmune disorder and added to the growing list of other immune disorders that are associated with Type 1 Diabetes and in a variety of patterns come to be known as the Autoimmune Polyglandular Syndromes. The value of this definition which you may want to discuss with your son's endocrinologist is that it would justify a special alertness for hypothyroidism and perhaps at sometime an assay of the other antibodies now measured routinely in the Diabetes Prevention Trial (DPT-1), namely anti-21-hydoxylase for Addison's Disease and anti-glutamyl transferase for the celiac syndrome. The chance of these being positive are less than 5% and of there being any clinical manifestations even smaller; but there is a case for being forewarned. A call to 1-800-425-8361 would tell you where the nearest lab was and how to submit samples.

If you have a chance to get to a medical library and to search MEDLINE you will find nearly 40 recent references on this theme under diabetes/vitiligo/human/english. In this particular case, though, PubMed is not as useful.

The pump story is especially intriguing because it flies in the face of current dogma, namely that you should not start using a pump at this young age and that you're supposed to achieve good control by conventional means before starting. Like you, I could find nothing on subcutaneous antibodies in the recent literature and in fact I think the idea must hark back to some work done about twenty years ago by Edwin Gale who is now Professor of Endocrinology at Bristol, England. What he did was to inject labelled beef insulin subcutaneously and show that absorption was very erratic indeed and that this accounted for most of the variability in blood sugars in some people. Much purer modern forms of insulin and especially lispro insulin [Humalog®] are known to be absorbed very evenly and especially so when delivered by pump. I don't think antibodies come in to it and indeed there was a study by Allen Drash from Pittsburgh showing that higher anti-insulin antibody titers were associated with improved control.

DO'B

Original posting 15 Apr 1998
Posted to Complications and Other

  
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Last Updated: Tuesday April 06, 2010 15:08:58
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