Diabetes Responsive to Intravenous but Not Subcutaneous Insulin: Effectiveness of Aprotinin

Patients with diabetes that is insensitive to subcutaneous insulin but sensitive to intravenous insulin have recently been described. We have studied this phenomenon in five female diabetics (14 to 31 years of age) who required excessive amounts of insulin (2.5 to 30.0 units per kilogram of body weight per day) to avoid recurrent ketoacidosis. Known causes of insulin resistance were excluded. All patients had normal responses to conventional doses of intravenous insulin (0.35 to 0.9 unit per kilogram per day). Four patients required continuous intravenous infusion of insulin for one to six months. When a mixture of aprotinin (a protease inhibitor) and regular porcine insulin was given subcutaneously, conventional doses (0.7 to 1.4 units per kilogram per day) produced euglycemia; plasma levels of free insulin rose, and ketonuria disappeared. Four patients had episodes of spontaneous, severe hypoglycemia before and during aprotinin therapy, necessitating continuous infusion of glucose for two to 14 days. Although no insulin was administered, hyperinsulinemia (50 to 2000 μU of free insulin per milliliter [359 to 14,350 pmol per liter]) was present. These findings suggest excessive degradation or sequestration of insulin at the site of injection. (N Engl J Med. 1981; 305:363–8.) FEWER than 1 per cent of adults with diabetes mellitus require more than 200 units of insulin per day to prevent marked hyperglycemia and ketosis. In diabetic children and adolescents, a need for insulin in excess of 2 units per kilogram of body weight daily suggests the presence of insulin resistance. 1 Excessive insulin requirements 2 have been observed in patients with antibodies in plasma that bind to insulin, 3 with abnormalities of the insulin receptors, 4 , 5 with an excess of insulin antagonists 6 , 7 such as glucagon and growth hormone, or with interference with normal insulin-receptor function by antibodies against the insulin receptor itself. 4 , 5 , 8 Cases . . .