Critical Low Catastrophe: A Case Report of Treatment-Refractory Hypoglycemia following Overdose of Long-Acting Insulin

Rashi Sandooja,Monisha Priyadarshini Kumar,Karla Detoya,John M Moorman,Osamu Isozaki

doi:10.1155/2020/8856022

Abstract

Overdose of long-acting insulin can cause unpredictable hypoglycemia for prolonged periods of time. The initial treatment of hypoglycemia includes oral carbohydrate intake as able and/or parenteral dextrose infusion. Refractory hypoglycemia following these interventions presents a clinical challenge in the absence of clear guidelines for management. Octreotide has sometimes been used, but its use is generally limited to sulfonylurea overdose. In this case report, we present a case of refractory hypoglycemia following an overdose of 900 units of long-acting insulin glargine that failed to respond to usual modes of therapy mentioned above. Stress-dose corticosteroids were then initiated, followed by subsequent improvement in IV dextrose and glucagon requirements and blood glucose levels. Hence, corticosteroids may serve as an adjunctive therapy in managing hypoglycemia and can be considered earlier in the course of treatment in patients with refractory hypoglycemia to prevent volume overload, especially when large volumes of dextrose infusions are required.

Highlights

Insulin is a mainstay of treatment in patients with type 1 diabetes mellitus (T1DM), and a significant proportion of patients with type 2 diabetes mellitus (T2DM) are insulin-dependent [1,2,3]
Management of insulin overdose poses a clinical challenge and may require modified treatment strategies, given the lack of consensus and guidelines. e objective of this report is to describe a case of intentional insulin overdose associated with refractory hypoglycemia and to discuss the integrative approach to managing this case
Prolonged continuous D10 IV infusions can lead to volume overload, and parenteral administration of higher concentrations of dextrose (e.g. 25% or 50%) requires invasive procedures to obtain central venous access [18]

Summary

Introduction

Insulin is a mainstay of treatment in patients with type 1 diabetes mellitus (T1DM), and a significant proportion of patients with type 2 diabetes mellitus (T2DM) are insulin-dependent [1,2,3]. In the U.K. Prospective Diabetes Study, the prevalence of hypoglycemia in patients with T2DM who were taking insulin was 11.2%, as compared to 3.3% in those taking sulfonylureas and 2.4% in those taking metformin [4]. Prospective Diabetes Study, the prevalence of hypoglycemia in patients with T2DM who were taking insulin was 11.2%, as compared to 3.3% in those taking sulfonylureas and 2.4% in those taking metformin [4] These prevalences represent usual medication use and do not account for the potential for insulin overdose, either intentional or unintentional. E objective of this report is to describe a case of intentional insulin overdose associated with refractory hypoglycemia and to discuss the integrative approach to managing this case Management of insulin overdose poses a clinical challenge and may require modified treatment strategies, given the lack of consensus and guidelines. e objective of this report is to describe a case of intentional insulin overdose associated with refractory hypoglycemia and to discuss the integrative approach to managing this case

Case Report

Discussion

Conclusions