Endocrine Abstracts

Insulin induced hypoglycaemia is a life threatening complication in T1DM. Sub-optimal counter regulatory response, with hypocortisolemia, threatens the recovery from insulin induced hypoglycaemia. We present a 28-year-old man with polyglandular autoimmune syndrome type 2 and life threatening hypoglycaemia, whose severe hypoglycaemic events were improved following introduction of CSII.

The patient was diagnosed with Addison’s disease in 2000 and T1DM in 2004. Basal bolus insulin treatment was associated with variable glycaemia control, HbA1c 7.5–10.0%. He experienced recurrent unpredictable episodes of hypoglycaemia many requiring third party intervention. Three episodes lead to hospitalisation, one where he was unconscious at home for 24 h. A lack of endogenous cortisol response may have prevented recovery from the hypoglycaemic events.

Intensive optimisation of hydrocortisone dose and basal insulin, including the use of continual glucose monitoring (GCM), proved difficult to cope with early morning hypoglycaemia and daytime episodes were not reduced despite the use of a carbohydrate counting approach.

CSII is indicated in patients with T1DM in those unable to maintain satisfactory glucose levels ‘without disabling hypoglycaemia’. Agreed goals for CSII were HbA1c <7.5%, reduction in fear and rates of severe hypoglycaemia. CSII was initiated with a reduced basal rate for 4 h before waking/hydrocortisone. Post initiation GCM also demonstrate glucose peaks following hydrocortisone which can be addressed by an increase in basal rate at these times. He has met and maintained his goals since initiation of CSII, HbA1c has fallen from 8.6 to 7.3% with no hypoglycaemic events in the last 3 months. Suboptimal endogenous cortisol response is a threat to recovery from insulin induced hypoglycaemia. The ability to vary basal insulin rates is an effective way of adjusting to the variations in cortisol levels associated with oral hydrocortisone replacement that can be associated with profound and prolonged hypoglycaemic episodes.