Endocrine Abstracts

Introduction: Patients with diabetes have nearly twice the risk of depression compared to general population. Prolonged hypoglycemia can occur with insulin overdose and treatment involves correction of hypoglycemia with oral or intravenous glucose supplementation, with glucagon or octreotide in some cases. Glucocorticoids are not routinely administered but can be used as an adjunct in severe cases. We present a case of intentional insulin overdose in a young diabetic patient with hypoglycemia who responded to additive intravenous hydrocortisone after showing minimal response to repeated administrations of dextrose.

Case description: A 29 year-old female with history of secondary diabetes from chronic pancreatitis with CFTR mutation and previous autologous islet transplantation presented to the emergency department with recurrent episodes of hypoglycemia that persisted despite ingesting high carbohydrate foods. She had a history of self-harm attempts. The patient was using an insulin pump in manual-mode and continuous glucose monitor. She reported that her insulin pump malfunctioned and took reduced dose of 12 units of insulin glargine from a 24-hour basal of 16.8 units the night prior to admission. Serum glucose on presentation was 57 mg/dl requiring 10% dextrose boluses every hour in addition to a dextrose infusion. Hypoglycemia persisted for over 12 hours since admission with lowest point-of-care glucose 19 mg/dl. She eventually admitted to taking 1 full pen of insulin lispro and 1 full pen of insulin glargine; 300 + 300 units = 600 units. For resistant hypoglycemia, a trial of IV hydrocortisone 100 mg followed by 50 mg 8 hours later resulted in subsequent improvement in glucose levels greater than 90 mg/dl. The patient later admitted that she never modified her pump settings and there was no malfunction.

Discussion/Conclusion: Our patient responded well to addition of hydrocortisone with improvement in hypoglycemia within hours after administration. Treatment with glucocorticoids has shown to counteract the resistant hypoglycemia due to insulin overdose in previous case reports. This case highlights a challenge of initial diagnosis due to patient limited disclosure and to consider high risk factors like previous suicide attempts, anxiety and depression in evaluation of hypoglycemia. Careful management of symptoms related to depression and developing a safety plan is integral to complete patient care. In conclusion, our case emphasizes the importance to recognize high risk factors for self-harm in diabetic patients and consideration for early intervention with glucocorticoids for persistent hypoglycemia if insulin overdose is suspected.