Abstract
IntroductionPrognostic factors in intentional insulin self-poisoning and the significance of plasma insulin levels are unclear. We therefore conducted this study to investigate prognostic factors in insulin poisoning, in relation to the value of plasma insulin concentration.MethodsWe conducted a prospective study, and used logistic regression to explore prognostic factors and modelling to investigate toxicokinetic/toxicodynamic relationships.ResultsTwenty-five patients (14 female and 11 male; median [25th to 75th percentiles] age 46 [36 to 58] years) were included. On presentation, the Glasgow Coma Scale score was 9 (4 to 14) and the capillary glucose concentration was 1.4 (1.1 to 2.3) mmol/l. The plasma insulin concentration was 197 (161 to 1,566) mIU/l and the cumulative amount of glucose infused was 301 (184 to 1,056) g. Four patients developed sequelae resulting in two deaths. Delay to therapy in excess of 6 hours (odds ratio 60.0, 95% confidence interval 2.9 to 1,236.7) and ventilation for longer than 48 hours (odds ratio 28.5, 95% confidence interval 1.9 to 420.6) were identified as independent prognostic factors. Toxicokinetic/toxicodynamic relationships between glucose infusion rates and insulin concentrations fit the maximum measured glucose infusion rate (Emax) model (Emax 29.5 [17.5 to 41.1] g/hour, concentration associated with the half-maximum glucose infusion rate [EC50] 46 [35 to 161] mIU/l, and R2 range 0.70 to 0.98; n = 6).ConclusionIntentional insulin overdose is rare. Assessment of prognosis relies on clinical findings. The observed plasma insulin EC50 is 46 mIU/l.
Highlights
Prognostic factors in intentional insulin selfpoisoning and the significance of plasma insulin levels are unclear
Toxicokinetic/toxicodynamic relationships between glucose infusion rates and insulin concentrations fit the maximum measured glucose infusion rate (Emax) model (Emax 29.5 [17.5 to 41.1] g/hour, concentration associated with the half-maximum glucose infusion rate [EC50] 46 [35 to 161] mIU/ l, and R2 range 0.70 to 0.98; n = 6)
CI = confidence interval; CPC = Cerebral Performance Category; Emax = maximum measured glucose infusion rate; EC50 = insulin concentration associated with the half-maximum glucose infusion rate; ICU = intensive care unit; Odds ratio (OR) = odds ratio; SAPS = Simplified Acute Physiology Score; TK/ TD = toxicokinetic/toxicodynamic
Summary
Prognostic factors in intentional insulin selfpoisoning and the significance of plasma insulin levels are unclear. We conducted this study to investigate prognostic factors in insulin poisoning, in relation to the value of plasma insulin concentration. Contrasting with the common occurrence of insulin-induced hypoglycaemia in type 1 diabetes patients, deliberate overdose with insulin are rarely reported [1]. In a series of diabetic poisoned patients, fewer than 5% of suicide attempts involved insulin [4]. In a series of nondiabetic poisoned patients presenting with toxic hypoglycaemia, fewer than 1% had self-injected insulin [5]. Prognostic factors in insulin overdose remain subject to debate, and the optimal modalities of glucose therapy are not known.
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