Butler PW, Légaré JF, White CW. Transient extreme insulin resistance in a patient requiring extracorporeal membrane oxygenation for cardiogenic shock: A case report. World J Diabetes 2025; 16(10): 111212 [PMID: 41113493 DOI: 10.4239/wjd.v16.i10.111212]
Corresponding Author of This Article
Patrick W Butler, Faculty of Medicine, Dalhousie University, 100 Tucker Park Rd, Saint John E2 L 4 L5, New Brunswick, Canada. patrick.butler@dal.ca
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Critical Care Medicine
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Case Report
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Oct 15, 2025 (publication date) through Oct 22, 2025
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World Journal of Diabetes
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Butler PW, Légaré JF, White CW. Transient extreme insulin resistance in a patient requiring extracorporeal membrane oxygenation for cardiogenic shock: A case report. World J Diabetes 2025; 16(10): 111212 [PMID: 41113493 DOI: 10.4239/wjd.v16.i10.111212]
World J Diabetes. Oct 15, 2025; 16(10): 111212 Published online Oct 15, 2025. doi: 10.4239/wjd.v16.i10.111212
Transient extreme insulin resistance in a patient requiring extracorporeal membrane oxygenation for cardiogenic shock: A case report
Patrick W Butler, Jean-François Légaré, Christopher W White
Patrick W Butler, Faculty of Medicine, Dalhousie University, Saint John E2L 4L5, New Brunswick, Canada
Jean-François Légaré, Christopher W White, Division of Cardiac Surgery, New Brunswick Heart Center, Saint John E2L 4L2, New Brunswick, Canada
Author contributions: Butler PW writing, drafting and editing of manuscript; Légaré JF review and editing of manuscript; White CW review, editing and data collection for manuscript. All authors have read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE checklist (2016) and have written and revised the text in accordance with the guidelines.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Patrick W Butler, Faculty of Medicine, Dalhousie University, 100 Tucker Park Rd, Saint John E2 L 4 L5, New Brunswick, Canada. patrick.butler@dal.ca
Received: June 27, 2025 Revised: August 1, 2025 Accepted: August 25, 2025 Published online: October 15, 2025 Processing time: 112 Days and 8 Hours
Abstract
BACKGROUND
Acute and extreme insulin resistance with persistent hyperglycemia requiring excessively high doses of insulin before rapidly resolving is rare and has been referred to as transient and extreme insulin resistance (TEIR). The underlying pathophysiology and optimal management of TEIR are poorly understood, and previous reports of TEIR in the literature are sparse. This report is the first description of TEIR in a patient requiring mechanical circulatory support (MCS).
CASE SUMMARY
A 62-year-old male developed cardiogenic shock and was placed on veno-arterial extracorporeal membrane oxygenation following percutaneous coronary intervention and successful revascularization. Over the next 24 hours, glucose levels rose and remained markedly elevated despite increasing insulin infusion rates and repeated boluses. The insulin infusion rate peaked at 450 units/hour, and the patient received 4300 units (33 units/kg) of insulin over the 24-hour period of peak insulin resistance. Insulin resistance resolved rapidly, necessitating an abrupt decrease in the insulin infusion rate and development of rebound hypoglycemia.
CONCLUSION
Onset of TEIR did not seem to correlate with end-organ hypoperfusion or vasoactive drug dosing.
Core Tip: This paper presents the first report of transient and extreme insulin resistance (TEIR) in a patient receiving mechanical circulatory support (MCS). TEIR is an exceedingly rare condition that occurs in critically ill patients and carries with it a high mortality rate and uncertain pathophysiology. Due to the implementation of MCS and vasoactive medication, this case is uniquely positioned to provide an observation on some of the previously proposed mechanisms of TEIR (tissue hypoperfusion and vasoactive drugs).
