THU391 A Case Of Unrecognized Hypoglycemia Due To Methadone Use In A Non-Diabetes Patient

Abstract

Abstract Disclosure: D. Owais: None. J.R. Fredrick: None. Y. Jamal: None. S. Sajnani: None. Introduction: Methadone is a rare cause of insulin-mediated hypoglycemia. Hypoglycemia can be manifested as autonomic instability (palpitations and diaphoresis) and neuroglycopenia (agitation and altered mentation). We present the case of hypoglycemia in a non-diabetic patient with no renal insufficiency and who was on a high dose of Methadone. Case: A 76-year-old male with a medical history of HTN, CAD, CVA, dementia, chronic opioid use (on methadone 80 mg) initially presented two times to an outside hospital for intractable seizures. The diagnosis of seizure disorder was made and was discharged on valproate. Per his wife, he had a few low blood sugars during those hospitalizations. Within a month of discharge, he was admitted to another hospital for severe bradycardia and had undergone pacemaker implantation. He was then discharged to nursing home (NH). In the NH, the routine laboratory work showed a serum blood glucose of 42; however, it was interpreted as a lab error. The next day, he developed severe metabolic encephalopathy, intractable seizures and transferred to our hospital. On arrival, serum blood sugar was 59, corrected by 50% of dextrose. His physical examination was significant for a thin-built elderly male, lethargic but in no acute distress. The dose of antiseizure medication was adjusted. The Methadone 80 mg daily was resumed. He continued to have intermittent hypoglycemia to as low as 33 despite being on intravenous (IV) dextrose solutions. His symptoms used to improve temporarily after the correction of hypoglycemia. (Positive Whipple’s triad). Blood cultures and urine cultures were negative. Serum cortisol level, IGF -1, TSH levels, blood pressure, and electrolytes were within normal limits. The hypoglycemia workup performed in a fasting state (off IV dextrose) showed endogenous hyperinsulinism with insulin level >3, C-peptide level >0.2, beta-hydroxybutyrate level of <2.7, and negative sulfonylurea screen. CT scan and ultrasound of the abdomen were performed to rule out insulinoma; however, it demonstrated complete atrophy of the pancreas. Therefore, a high dose of methadone was assumed to cause hypoglycemia, as the patient had no hypoglycemic episodes when he could not receive two doses of methadone due to encephalopathy. The trough levels of methadone in the blood were high at 650 ng/dl. Methadone dose was tapered to 60 mg daily. He was also started on octreotide to manage his hypoglycemia. However, the patient developed severe pneumonia, and family opted for hospice. Conclusion: Our case is unique as the patient was developing severe signs of hypoglycemia, including bradycardia and seizures, and treated with a pacemaker and antiseizure medications. His Methadone-induced hypoglycemia was identified late as the cause of his symptoms. Therefore, it is crucial to recognize this side effect of Methadone in differentials in a patient with hypoglycemia. Presentation: Thursday, June 15, 2023