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Case report A 70-year-old Philippines woman with a history of adult-onset asthma and hypertension was referred with suspected localised insulin allergy. She had been diagnosed with type 2 diabetes in 2010 and treated initially with oral antidiabetic agents. She was started on biphasic insulin aspart (NovoMix 30®) in February 2015 as the HbA1c concentration had risen to 75 mmol/mol. After 3 months she developed red itchy blotches at her injection sites. The redness and itching occurred immediately after subcutaneous injection, and within 30 minutes a hard lump appeared which took several days to disappear. She had no generalised rash or other features of anaphylaxis. Her injection technique had been checked to exclude intradermal injection. The insulin had been changed to biphasic porcine isophane (Hypurin Porcine 30/70®) and then to insulin glargine (Lantus®) with no change in the symptoms. Her GP had prescribed an oral antihistamine and topical 1% hydrocortisone cream which had not helped. The insulin was discontinued in July 2015 and her diabetes was treated with gliclazide MR, metformin MR and saxagliptin in maximum doses. She was seen by a consultant allergist who ascertained that she had been diagnosed with asthma at the age of 40 when she moved to England, and also suffered from occasional hay fever symptoms. A local reaction to her insulin injections was diagnosed. Specific IgE levels to human insulin (ImmunoCAP c71) and bovine insulin (ImmunocCAP c73) were elevated at 1.92 kUA/L and 3.31 kUA/L, respectively, indicating that the reactions were due to insulin rather than an excipient in the preparations. Skin prick testing with the insulin preparations was not performed. Skin prick testing to common aeroallergens was negative. An obstructive pattern on spirometry (FEV1/FVC 69%) was noted and she was prescribed both Symbicort and salbutamol inhalers. Off insulin her diabetic control deteriorated rapidly and she became symptomatically hyperglycaemic (HbA1c 92 mmol/mol) and lost weight. Her anti-GAD antibody was positive, 39 IU/mL (reference range 0–9 IU/mL), and her diagnosis was changed to type 1 diabetes. It was explained that treatment with insulin was the only treatment likely to bring the diabetes under adequate control, so she agreed to attempted desensitisation. This was done using a modification of the rapid desensitisation protocol1 using serial subcutaneous injections of insulin aspart (NovoRapid®) at an initial concentration of 0.0001 units/mL 0.9% saline. This was undertaken as an inpatient, as she was felt to be at higher risk of anaphylaxis because of her asthma. Oral cetirizine was continued during and afterwards. Only when undiluted insulin (100 units/mL) was injected did a localised reaction with redness and oedema appear at the injection site. There were no features of a systemic reaction and her asthma remained stable throughout. She was then started on continuous subcutaneous 1 Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicester, UK 2 Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK

Desensitisation to subcutaneous insulin using CSII followed by i-Port Advance™