PSUN277 Symptomatic Hypoglycemia Associated with Over The Counter Supplement

Abstract

Abstract Background Insulin autoimmune syndrome (IAS), first described in 1970 in Japan, is characterized by spontaneous fasting or postprandial hypoglycemia with evidence of elevated serum insulin levels and anti-insulin antibodies in individuals with no prior exposure to exogenous insulin. IAS has been mostly reported in Asia. Genetically susceptible individuals, with HLA-DR4, are reported to have higher incidence of IAS. Possible triggers include Sulfyhdryl group containing compounds. Clinical Case We report a case of a 25-year-old female of asian descent (133lbs, BMI 22.3 kg/m2) with no significant medical or surgical history, who was referred for an evaluation of hypoglycemia. She did not have diabetes mellitus and never administered insulin or sulfonylureas. Patient started a glutathione supplement for skin care and six months later she switched to glutathione-blend supplement (total daily intake Glutamic Acid 360 mg, Glycine 400mg, L-Cysteine 240mg, NAC 200 mg, Vitamin C 200mg, Alpha Lipoic Acid 100mg, Grapeseed Extract 50mg). Patient reported being asymptomatic for the initial 3 months of taking the new glutathione blend supplement. At that time she developed symptoms of dizziness, diaphoresis, palpitations, muscle weakness, headaches and sugar craving. She reported that these symptoms resolved with administration of glucose and recurred every 2-3 hours after meals and overnight. Baseline continuous glucose monitor (CGM) data showed average glucose of 74 mg/dL, 60% in target range (70-180mg/dL), 38% Low glucose levels (54-69 mg/dL), and 2% very low (<54 mg/dL) Her baseline labs while on glutathione blend supplement showed serum glucose 71 mg/dL, insulin 815 uIU/mL (UNL 25 uIU/mL), proinsulin 18.6 pmol/L (UNL 10 pmol/L), c-peptide 4.2 ng/mL (UNL 4.4 ng/mL), insulin antibodies > 625 uU/mL (<5 uU/mL negative). A week after supplement discontinuation, patient's symptoms have improved with reduction in frequency of hypoglycemia. Serum markers were repeated on 3 separate occasions (at 2 weeks, 3 months, and 5 months off supplement). All markers of insulin production were progressively decreasing. Insulin antibodies remained above the upper limit of the detection. By five months off supplement, she was able to fast for 6 hours without episodes of hypoglycemia. At that time her labs showed serum fasting glucose 83 mg/dL, insulin 286 uIU/mL, proinsulin 6.7 pmol/L, c-peptide 3.3 ng/mL, insulin antibodies > 625 uU/mL. CGM data at five months off supplement showed average glucose of 95 mg/dL, 100% in target range. Conclusion This is a rare case of supplement induced insulin autoimmune syndrome due to which the patient developed profound hypoglycemia. This case illustrates that once the supplement (alpha lipoic acid and glutathione) is discontinued there is an improvement in clinical and laboratory markers of hypoglycemia. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.