Department of Diabetes & Endocrinology, St Vincent's Hospital, Melbourne, Australia.
J Clin Endocrinol Metab. 2020 Apr 1;105(4). doi: 10.1210/clinem/dgz301.
Insulin autoimmune syndrome (IAS) is characterized by hyperinsulinemic hypoglycemia with elevated anti-insulin antibodies. Most commonly observed in the Japanese population, elsewhere it is rare and associated with autoimmune diseases, plasma cell dyscrasias, or sulfhydryl group medications. The active metabolite of clopidogrel has a sulfhydryl group and here we report a case of clopidogrel-induced IAS.
A 67-year-old man was admitted with severe hyperinsulinemic hypoglycemia requiring continuous intravenous infusion of 10% dextrose to sustain euglycemia. His symptoms of hypoglycemia had started after commencing dual antiplatelet therapy (including clopidogrel) for ischemic heart disease 9 months earlier. The hypoglycemia was associated with elevated insulin, proinsulin, c-peptide, and anti-insulin antibody titers as well as the HLA-DRB1*04 haplotype. Multiple localizing studies were negative for an insulinoma. A diagnosis of IAS was thus made. Clopidogrel cessation, oral dexamethasone, and diazoxide therapy were not sufficient to safely wean the dextrose infusion. Plasma exchange was ultimately effective.
This case highlights a case of severe IAS. Given the ubiquity of clopidogrel, IAS should be remembered as a rare adverse effect.
胰岛素自身免疫综合征（IAS）的特征是高胰岛素血症伴抗胰岛素抗体升高引起的低血糖。它在日本人群中最为常见，在其他地方则较为罕见，与自身免疫性疾病、浆细胞异常或含巯基药物有关。氯吡格雷的活性代谢物具有巯基，我们在此报告一例氯吡格雷引起的 IAS。
一名 67 岁男性因严重高胰岛素血症性低血糖症入院，需要持续静脉输注 10%葡萄糖以维持血糖正常。他的低血糖症状始于 9 个月前因缺血性心脏病开始双联抗血小板治疗（包括氯吡格雷）时。低血糖症与胰岛素、胰岛素原、C 肽和抗胰岛素抗体滴度升高以及 HLA-DRB1*04 单倍型有关。多项定位研究均未发现胰岛素瘤。因此，诊断为 IAS。停用氯吡格雷、口服地塞米松和二氮嗪治疗不足以安全停用葡萄糖输注。最终采用血浆置换有效。
本病例强调了一例严重的 IAS。鉴于氯吡格雷的普遍性，IAS 应被视为一种罕见的不良反应。
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