Reduction in Subcutaneous Insulin Requirements in Tetraplegic Type 1 Diabetic with Cervical Spinal Cord Injury Following Pramlintide Treatment

ABSTRACT Objective To report a massive increase in subcutaneous insulin requirements following spinal cord injury in a type 1 diabetic and how it was managed over a 22-month period with pramlintide. Methods A case report and brief literature review is presented. Results The patient is a 43-year-old male who was diagnosed with type 1 diabetes mellitus at age 18. He remained relatively well-controlled without end-organ complications until age 37, when he developed a spinal epidural abscess following a methicillin-resistant Staphylococcus aureus cellulitis of the foot. The patient became ventilator-dependent and tetraplegic. He remained in rehabilitation for 18 months and returned home with a total daily dose of subcutaneous insulin of 600 U (4 U/kg); a 500 U increase over his prespinal cord injury requirements. Total daily intravenous insulin requirement was determined to be 259 U (1.96 U/kg). The patient was started on pramlintide. Twenty-two months after the onset of pramlintide treatment his total daily dose of subcutaneous insulin was decreased to 150 U (1.3 U/kg). Conclusion Maintenance of glycemic control and obesity in type 1 diabetics with spinal cord injury may be complicated by autonomic dysregulation and the inability to induce activity-related lifestyle changes. Our patient exhibited clinical evidence of impaired subcutaneous insulin absorption that was not ameliorated by site changes, leading to massive insulin requirements which greatly reduced his quality of life. Following treatment with pramlintide, he decreased the volume of his insulin injections and lost 19 kg (41 pounds). Uncovering the precise mechanisms by which pramlintide benefited our patient requires further studies.