Endocrine Abstracts

A 16-year-old female with type 1 diabetes presented with ketotic hyperglycaemia and had a 13-week admission with presumed Subcutaneous Insulin Resistance Syndrome (SIRS). She was on a hybrid closed-loop system (Omnipod 5 & DEXCOM G6), using Fiasp. She has multiple dermatological diagnoses - hyperhidrosis, ichthyosis, keratosis pilaris and spontaneous surgical emphysema. She started on a sliding scale of intravenous insulin, adjusted according to her (limited) response to various subcutaneous insulins tried. The following were unsuccessful regimes: Tresiba 40 units alongside the Omnipod 5mm angled cannula with Fiasp, Novorapid, Actrapid, Humalog, Lyumjev and Apidra. Her TDD (total daily dose), reached ~500 units via her pump. Longer needles and soft sets were tried. Corrections were administered via pen alongside these regimes (using both 8mm and 12mm needles). She was changed from Tresiba (100units/ml) to Toujeo (300units/ml) to protect her sites. This was increased to 264units. Humalog and Lyumjev were tried via a Medtronic 780G pump with a 10mm steel needle. A Humalog-Heparin mix was tried before pump treatment was discontinued. She moved to HumulinR(U500) via pens alongside increasing doses of Toujeo. There was no response at a TDD of 1440 units (1200 units HumulinR and 240 units Toujeo). Her initial insulin antibodies, run in the Surrey laboratory, were reported as ‘positive’. 10 weeks into admission concerns were raised regarding issues with her intravenous insulin. Multiple intravenous lines appeared to have been tampered with. She refused to see clinical psychology. She was referred to the National Severe Insulin Resistance Service, Cambridge. Her insulin IgG antibody was 3 mg/l (0-5 mg/l) via Cambridge laboratory and was reported as negative. Subcutaneous Actrapid was resumed via pens; with staff strictly administering all injections. There was an immediate response, the patient was weaned off intravenous insulin within 36 hours. Confounders in this case included the reported delivery of insulin through the pump (visible on the pump settings), her dermatological diagnoses, level of supervision and reported desire for discharge. Furthermore, it was charted injections were being ‘administered’ by nursing staff when in fact the patient was being observed self-administering. This case provides significant learning on the complexities of managing adolescent diabetics.