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It could be a sensitivity or a paradoxical reaction if their detoxification pathways are congested (including the interstitium and liver)

After positively identifying my patient (my lab supervisor), and double checking that the insulin type (rapid acting Humalog) was accurate and not expired, I proceeded to uncap the needle, picked up the vial of insulin and then promptly botched the draw by ramming the tiny needle tip into the metal seal of the insulin vial, rendering the needle dirty, dull and useless

The most common cause id due to a condition called pernicious anaemia

Note that this is a convenient form of calculationnot the definition of clearance