Abstract #1403051: Hypoglycemia After Ingestion of Street “Valium” Containing Glyburide, Alcohol, and Cocaine

Abstract

Sulfonylureas increase the release of endogenous insulin, which can lead to hypoglycemia with overdose or ingestion by nondiabetic patients. Alcohol is metabolized by the liver resulting in decreased gluconeogenesis which can lead to hypoglycemia. Cocaine is not known to cause hypoglycemia but cocaine use and hypoglycemia can have a similar clinical presentation. A 33-year-old male with a history of narcotic dependence and anxiety was admitted after being found unresponsive and diaphoretic. Paramedics reported a glucose of 18 milligram per deciliter (mg/dL) that increased to 109 mg/dL after D50W administration. He regained consciousness at the scene but developed recurrent hypoglycemia. Prior to the medical encounter, the patient bought on the street and ingested 2 unmarked light blue pills thought to be valium to treat his anxiety. Subsequently, he developed diaphoresis and weakness and consumed cocaine and alcohol in attempt to relieve these symptoms. Twenty hours after the initial ingestion of the light blue pills, patient lost consciousness. Venous glucose in the emergency room was 15 mg/dL. Initiation of D50W infusion progressively improved blood glucose values over twenty hours. Once alert and oriented, the patient reported no personal or family history of diabetes. Toxicology screen was positive for benzodiazepines, cannabis, and cocaine. Laboratory values were notable for insulin of 47.4 milli-international units per milliliter (mIU/mL) (2.6-24.9), C-peptide of 5.4 nanograms per milliliter (ng/mL) (1.1-4.4), and glucose of 44 mg/dL. Patient underwent a 72 hour fast which did not suggest insulinoma. Sulfonylurea screen was positive for glyburide. Patient was discharged home in stable condition. Sulfonylurea induced hypoglycemia leads to clinical sedation, mimicking the effects of benzodiazepines and opioids. Sulfonylureas can be sold on the street, misbranded as benzodiazepines, or mixed with opioids. This has opened a window of opportunity for misuse of these medications. Alcohol consumption can cause hypoglycemia, however the mechanism differs from sulfonylurea, opioid, or benzodiazepine induced hypoglycemia. When taken in combination, severe hypoglycemia can result. Physicians should be aware of this possibility and consider intentional or unintentional sulfonylurea abuse, with or without other drugs.