Some rare insulin resistant states exist in which hundreds or even thousands of units of insulin may be ineffective. They are often associated with lipodystrophy, hyperlipidaemia, and acanthosis nigricans. Type A insulin resistance is due to genetic defects in the insulin receptor or in the post-receptor pathway. Type B insulin resistance occurs as a result of IgG autoantibodies directed against the insulin receptor; it is often associated with other autoimmune disorders such as systemic lupus erythematosis, and it is much commoner in women of African descent. Management of these conditions can be very difficult and specialist texts should be consulted.
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