Insulin edema

Insulin edema has been described in children with newly discovered diabetes (116). 

When thiazolidinediones are combined with insulin, edema can develop if there is cardiac dysfunction (296). 

Chelliah A, Burge MR. Insulin edema in the twenty-first century review of the existing literature. J Invest Med 2004 52 104-8. 

In 556 patients taking insulin, edema developed in 18% of those who took pioglitazone 30 mg/day, 13% of those who took 15 mg/day, and 7.0% of those who took placebo (97). The authors undertook a retrospective review of 79 subjects taking thiazolidinediones and insulin 20 had developed edema. The mean dose of pioglitazone was 24 mg/day and rosiglitazone 6 mg/day. The mean time to edema was 135 days. They reported a 77% resolution rate with various interventions. Whether thiazolidinediones need to be withdrawn in patients with edema has been discussed in several papers. 

Lipodystrophy can also result from insulin therapy and is characterized by atrophy of subcutaneous fat. Insulin edema is manifested by a generalized retention of fluid. Insulin resistance arises when there is an excess insulin requirement that exceeds 200 units per day. 

Rare complications are lipoatrophy or hjrpertrophy and insulin edema. Insulin has to be given by injection, with pumps or specific devices for intensive therapy, which all generate specific problems. Other ways of administrating insulin are still experimental. 

Insulin edema is a rare complication, more often seen in the earlier years of insulin therapy (SEDA-11, 364). It is mostly seen when dysregulated patients with progressive weight loss are treated with relatively high amounts of insulin. Reduced sodium excretion (88), sodium reabsorption, and water retention by a possible direct action of insulin on the kidney may be involved (89). The role of aldosterone or of inhibition of the renin-angiotensin-aldosterone system in insulin edema is unclear. Insulin edema is a specific adverse effect, but it can aggravate pulmonary edema, congestive heart failure, and hypertension. Treatment consists of reduction of the insulin dose, after which the edema resolves within 3 days. 

Thiazolidinediones may produce fluid retention and edema however, the mechanism by which this occurs is not completely understood. It is known that blood volume increases approximately 10% with these agents, resulting in approximately 6% of patients developing edema. Thus, these drugs are contraindicated in situations in which an increased fluid volume is detrimental, such as heart failure. Fluid retention appears to be dose-related and increases when combined with insulin therapy. 

Fluid retention may occur, perhaps as a result of peripheral vasodilation and/or improved insulin sensitization with a resultant increase in renal sodium and water retention. A dilutional anemia may result, which does not require treatment. Edema is reported in 4% to 5% of patients when glitazones are used alone or with other oral agents. When used in combination with insulin, the incidence of edema is about 15%. Glitazones are contraindicated in patients with New York Heart Association Class III and IV heart failure and should be used with great caution in patients with Class I or II heart failure or other underlying cardiac disease. 

Albumin 18-20 Maintains plasma oncotic pressure transports small molecules Dehydration, anabolic steroids, insulin, infection Overhydration, edema, kidney insufficiency, nephrotic syndrome, poor dietary intake, impaired digestion, burns, congestive heart failure, cirrhosis, thyro id/adrena / pitu itary hormones, trauma, sepsis... 

M/sce/Zaneows-Allergic reactions. Sodium retention and edema may occur, particularly if previously poor metabolic control is improved by intensified insulin therapy. Antibody production. 

Pioglitazone - Pioglitazone when used in combination with sulfonylureas, metformin, or insulin caused an increased incidence of edema. 

Rosiglitazone - Reports of anemia were greater in patients treated with a combination of rosiglitazone and metformin compared with rosiglitazone monotherapy. Edema was reported with higher frequency in the rosiglitazone plus insulin combination trials. 

Benazepril (Lotensin) [Antihypertensive/ACEI] Uses HTN DN, CHF Action ACE inhibitor Dose 10 0 mg/d PO Caution [C (1st tri), D (2nd 3rd tri), +] Contra Angioedema, Hx edema, bilateral RAS Disp Tabs 5, 10, 20, 40 mg SE Symptomatic i BP w/ diuretics dizziness, HA, nonproductive cough Interactions T Effects W/ a-blockers, diuretics, capsaicin effects W/ NSAIDs, ASA T effects OF insulin, Li T risk of hyperkalemia W/ trimethoprim K-sparing diuretics EMS Monitor EGG for signs of hyperkalemia angioedema is rare but can occur persistent cough /or taste changes may develop OD Profound hypotension treat w/ IV fluid... 

Julie Singer is a 55-year-old white woman who was admitted to the emergency department in acute distress. A previous physical examination showed hypertension and diabetes mellitus type 2. The patient s present medications include enalapril 40 mg, nifedipine 60 mg, and 100 U insulin. A physical examination revealed prominent ankle edema, a palpable spleen, and hepatomegaly. Chest radiography revealed diffuse cardiac enlargement and left ventricular hypertrophy. Based upon the history and clinical hndings, what is your diagnosis and what treatment do you recommend ... 

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