Desensitization is started with a dose that is 10 times less than the minimum, causing a positive reaction when setting skin tests. This treatment is carried out only in a hospital. First, short-acting insulin preparations are used, later, intermediate-acting insulin preparations are added to them. In some cases, such as diabetic ketoacidosis and hyperosmolar coma, accelerated desensitization is used. In these cases, insulin is injected s / c every 15-30 minutes. The insulin preparation and the initial dose for desensitization are selected using skin tests.
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If a local allergic reaction to insulin develops during desensitization, the dose of the drug is not increased until the reaction persists. With the development of an anaphylactic reaction, the dose is halved, after which it is increased more smoothly. Sometimes, with an anaphylactic reaction, the desensitization regimen is changed, reducing the time between insulin accutane injections.
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Insulin resistance due to immune mechanisms: With a rapidly increasing need for insulin, hospitalization and examinations are necessary to rule out non-immune causes and stabilize the insulin dose. For treatment, it is sometimes sufficient to switch to purified porcine or human insulin, and in some cases to more concentrated (500 mg / day) insulin solutions or to protamine-zinc-insulin. If there are sharp metabolic disturbances and the need for insulin increases significantly, prescribe prednisone, 60 mg / day orally (for children - 1-2 mg / kg / day orally). During treatment with corticosteroids, plasma is constantly monitored, since with a rapid decrease in insulin requirements,develop hypoglycemia. After reducing and stabilizing the need for insulin, prednisone is prescribed every other day. Then its dose is gradually reduced, after which the drug is canceled.
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Allergic reactions to insulin can be local and general. They develop both on insulin itself and on impurities in the preparation, including prolongators, preservatives, and stabilizers. Young people and women are more predisposed to the development of allergic reactions. They rarely occur in people over 60 years of age. Allergic reactions usually develop in the first 1-4 weeks of insulin treatment, less often immediately after the start of insulin therapy. If a systemic reaction occurs (urticaria or Quincke's edema), signs of inflammation are usually observed at the injection site.
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Isotretinoin, in which 15-30 minutes after its administration, pale pink erythema, urticaria or more pronounced skin changes appear at the injection site; delayed, developing 24-30 hours after injection and characterized by the appearance of infiltrates at the injection site. Clinically, there are 3 types of allergy to immediate type insulin: local - an allergic reaction with inflammatory changes only at the injection site; systemic - an allergic reaction outside the injection site; a combination of local and systemic reactions.
Skin manifestations of insulin allergy are observed in 8-10% of patients, generalized urticaria occurs in OD-0.4% of cases, anaphylactic shock is very rare. The generalized reaction is manifested by weakness, fever, urticaria, accutane, joint pain, dyspeptic disorders, angioedema.
Rare cases of unusual allergic reactions are described, characterized by a slow, gradual development, a feverish state with the onset of pulmonary edema, which disappears after insulin is discontinued. Rarely, Arthus-type allergic reactions with aseptic necrosis of the subcutaneous tissue at the injection site also occur.
If an allergic reaction develops to any drug, it must be discontinued. The complexity of the problem lies in the fact that the life-saving insulin replacement therapy cannot be canceled. The first thing to do with an allergy to insulin is to transfer the patient to the least immunogenic drug.
It is a single-acting human insulin with a neutral pH. In a number of patients, this is sufficient to solve the problem of allergies, especially in patients with allergies to beef or sour insulin, insulin impurities. In parallel, antihistamines are prescribed: diphenhydramine, diazolin, tavegil, diprazine, 10% calcium chloride solution, etc. To accelerate the resorption of skin seals in the absence of other manifestations, calcium chloride electrophoresis is recommended on the affected areas.
For the treatment of patients with insulin allergy, the method of hyposensitization with small doses of the drug is used. In this case, insulin enters the body in a dose insufficient for the manifestation of an allergic reaction.
Such small, with a gradual increase in insulin doses, cause the formation of immunological tolerance, including the activation of regulatory cells of the immune system that suppress antibody production.
Insulin is diluted with isotonic sodium chloride solution so that 0.1 ml of its solution contains 0.001 IU. To do this, 4 units are diluted in 40 ml of isotonic sodium chloride solution or water for injection; 1 ml of the resulting solution is diluted in 9 ml of isotonic sodium chloride solution or water.
Begin to inject with 0.1 ml intradermally into the forearm. Every 30 minutes, the introduction is repeated, doubling the concentration - 0.002, then 0.004 and 0.008 IU. On the 2nd day, 0.01, 0.02, 0.04 and 0.08 IU are administered, on the 3rd and 4th day - 0.25, 0.5, 1 and 2 IU. If allergic manifestations persist on the 2nd day, the dose is not increased, insulin is re-introduced at the same dosage.
Boiled insulin is used for sorption of anti-insulin antibodies. Before use, the vial of insulin is boiled in a water bath for 5 minutes. With a severe reaction, you can start the introduction of insulin with small doses, as described above. Such insulin will not show its hormonal action.
It will be slowly absorbed, and a depot of insulin will be created at the injection site to attract and absorb antibodies. In the future, boiled insulin is gradually replaced with regular insulin. At the same time, desensitizing therapy is carried out. Sorption of antibodies to insulin can be carried out using hemosorption and plasmapheresis. Particularly promising is specific affinity plasmapheresis, which fixes and removes precisely certain antibodies.
To stimulate T-cell reactions in order to suppress antibody formation, levamisole (accutane) is used, which has a certain modulating effect on the immune system. The treatment regimen is as follows: 1st stage - desensitizing therapy with insulin in various dilutions for 3-4 days; 2nd stage - the use of levamisole in 3-day courses of 150 mg at night with an interval of 10 days.
Adverse reactions to insulin preparationsnot related to the biological action of the hormone insulin. Currently, all insulin preparations are highly purified, i. practically do not contain protein impurities, and therefore the immune side reactions caused by them (Isotretinoin, insulin resistance, lipoatrophy at the injection sites) are now rare.
