Endocrine Abstracts

Section 1: Case history: A 62 year old man presented with a three month history of abdominal bloating and discomfort, loose stools and weight loss. This progressed to hypoglycaemic symptoms that occurred initially after exercise. Symptoms included confusion and light-headedness, fatigue, cold sweats and shakiness. The patient had to eat regularly to prevent hypoglycaemia which resulted in weight gain. Hypoglycaemic episodes increased in frequency to the point where the patient had to live a sedentary lifestyle to avoid becoming symptomatic.

Section 2: Investigations: Fasting capillary glucose fell to 2.3 mmol/L with inappropriately elevated insulin and c-peptide. CT was consistent with T4a, N1, M1 disseminated pancreatic tail malignancy. Liver biopsy demonstrated a well differentiated neuroendocrine tumour, grade 2, likely metastatic to the liver. A whole-body NM tumour imaging SPECT CT scan showed an intense abnormal tracer uptake projected over the pancreatic tail and multiple somatostatin receptor positive hepatic deposits. The disease was unresectable.

Section 3: Results and treatment: Initially, patient was given lifestyle advice. Recurrent hypoglycaemic episodes at home led to hospital admission and trial of short acting somatostatin analogue, Octreotide. Flash glucose monitoring (FGM) was initiated in the form of Free Style Libre to enable monitoring of blood glucose levels. Following an initial positive response to Octreotide, the long-acting somatostatin analogue, Lantreotide was administered and patient was discharged home. Further hypoglycaemia resulted in hospitalisation for IV dextrose and trial of Diaxozide. Everolimus, was then added to his treatment. The use of continuous glucose monitoring with cloud based storage of glucose results provided both the patient and clinical team a detailed record of glucose control and allowed much of his treatment to be provided as an outpatient.

Section 4: Conclusions and points for discussion: It can be difficult to achieve normal glycaemic levels during medical management of insulinoma and can often result in hospital admission. This case is unique because FGM combined with a remote cloud-based diabetes management system has allowed physicians to monitor the patient’s glucose levels remotely. Frequent adjustments to patient’s medications have overall reduced the frequency of hypoglycaemic episodes. In conclusion, FGM has advantages to both patients and clinicians; patient confidence and quality of life is not only improved but the clinician also has the ability to manage this complex diagnosis as an outpatient. Overall, this reduces patient time in hospital, improves patient safety and maximises clinical outcomes.