Mycophenolate Mofetil and Plasmapheresis as a Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies

Abstract: Objective Insulin antibody (IA)-mediated insulin resistance (IR) is a rare condition for which immunosuppressive regimens have been described, however these raise the risk of infection and the drugs may not be metabolized effectively in patients with liver disease. We present a patient with type 2 diabetes mellitus, antibody-mediated IR, and decompensated cirrhosis, in whom mycophenolate mofetil and centrifugal plasmapheresis were used to achieve glycemic control. Methods Laboratory evaluation included IA levels, c-peptide, IGF-1, growth hormone, salivary cortisol, zinc transporter 8, GAD-65, and islet-cell antibodies. Centrifugal plasmapheresis and mycophenolate mofetil were used to treat the patient. Continuous glucose monitoring was implemented to monitor glycemic control pre- and post-therapy. Results A 61-year old male with type 2 diabetes requiring >800 units of daily insulin presented with acute decompensation of his pre-existing cirrhosis from recurrent diabetic ketoacidosis. Laboratory values confirmed an IA level of >625 uU/mL (reference: Conclusion This is the first report in which mycophenolate mofetil and centrifugal plasmapheresis were used to mitigate the effects of IA-mediated IR in a cirrhotic patient. We recommend further studies to determine the utility of this treatment to improve care for patients at high risk for infection with IA-mediated IR.