The incidence of drug-induced severe hypoglycemia could be higher than is currently estimated. We reviewed our three-year experience with drug-induced hypoglycemia in 50 patients of type 2 diabetes mellitus (29 men, 21 women, median age 75.6 years, range 49-97) who presented with disturdance of consciousness. Of the 50, 36 patients were being treated with a sulfonylurea, 13 with insulin, and 1 with both a sulfonylurea and insulin. The HbA₁c was 6.0% or less 23 patients. The severe hypoglycemia in our patients could be explained mainly by an inadequate prescription of sulfonylurea to high-risk patients or patients with renal dysfunction, liver dysfunction or reduced energy intake. High-risk patients for drug-induced hypoglycemia are elderly patients and patients with renal dysfunction. Of the Total, 24 patients were found in a coma, and the median duration of coma estimated from their histories was 7.3 hours (range 1-24). Three patients estimated to have been is a state of hypoglycemia for more than 10 hours did not recover from the coma. The older the patients of diabetes mellitus become, the more frequently doctors other than specialists are involved in the treatment of diabetes mellitus. Adequate guidelines are desired, especially for the treatment of diabetes mellitus in elderly patients or those with renal dysfunction.

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The clinical features of 207 patients with diabetes mellitus who required hospitalization for the treatment or prevention of infections were investigated to consider effective strategies for the treatment of infections in diabetic patients. The most frequent type of infection was respiratory infection (41%), followed by urinary tract infection (24%) and skin/soft tissue infections (17%). When the subjects were divided by the leukocyte count and serum CRP level into mild, moderate and severe groups, the severe group had higher random blood glucose levels and required higher daily total insulin doses. There was also a significant association between the severity of infection and the incidence of ketosis or ketoacidosis. The most common causative microorganisms of pneumonia in the diabetic patients were methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, Streptococcus pneumoniae, Pseudomonas aeruginosa and Mycoplasma (in descending order). Because severe infections complicating diabetes mellitus can induce marked elevation of the blood glucose levels as well as increase the risk of complication by ketosis or ketoacidosis, diabetic patients with infections need immediate amelioration of the abnormal glucose metabolism, identification of the pathogenic microorganism and treatment with appropriate antibiotics.

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An 84-year-old man with type 2 diabetes treated with human insulin from April 2000 to January 2003 experienced a progressive daily insulin dose increase up to 80 U/day during this period and ¹²⁵I-insulin binding was 96%. His regimen was converted from human insulin to almost the same dose of insulin aspart. In July 2004, his blood glucose rose abruptly (FBG>300 mg/dl) and could not be controlled even with more than 90 units of insulin aspart. We then treated him with insulin lispro, after which his blood glucose rapidly decreased and was well controlled with 12 U of insulin lispro 3 times daily before each meal. We found that insulin antibodies specific to insulin aspart were 15.1% and cross-reacting to human insulin/insulin aspart were 47.2%.
Scatchard analysis of insulin antibodies showed a low-affinity constant and an extremely high binding capacity of high-affinity sites. Insulin antibody binding resembled that in insulin autoimmune syndrome. We concluded that he developed severe immunological insulin resistance caused mainly by antibodies cross-reacting to human insulin/insulin aspart. Insulin lispro seemed less reactive to his antibodies and was effective for his glycemic control.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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