Endocrine Abstracts

Diabetes Mellitus is one of the leading causes of morbidity and healthcare costs internationally. Innovations in treatment options however, including insulin analogues, continue to emerge. While insulin therapy may be required for certain patients with Type 2 Diabetes Mellitus (T2DM), it bestows upon them the opportunity for potential harm, namely insulin overdoses, whether accidental or intentional. This case details an intentional ultra-long-acting insulin analogue overdose in a 44-year-old female with T2DM, known mixed personality disorder and previous deliberate self-harm. A total of 1500iu of insulin degludec were reported to be injected pre hospital, requiring 3L 10% dextrose, 200ml 50% dextrose 5 mg IM glucagon and 300 mg of IV hydrocortisone within the first 32 hours, resulting in a mean BGL of 7.6 mmol/l (fasting 4 mmol/l – 5.5 mmol/l) with 2 hypoglycemic events of 3.4 mmol/l and 2.9 mmol/l. Inpatient care was complicated by treatment and investigation refusal, with self-removal of IV access including CVC. The patient had a psychiatric review and the decision to treat the patient in her best interests was taken. She required decreasing amounts of IV dextrose boluses, glucagon, and hydrocortisone, and was transferred to the psychiatric ward on day 10 of her admission with a mean BGL of 11 mmol/l with a serum insulin level decreasing from a peak of 2802mIU/l to 105mIU/l (fasting < 25mIU/l). As increasing numbers of patients require and are prescribed insulin therapy, the risk of negative outcomes rises. In potential high-risk patient groups, including patients with suicidal ideation, the risks of insulin therapy may outweigh the potential benefit in their glycemic control. As diabetes continues to emerge as a condition requiring multidisciplinary-team input, this case demonstrates the need for the implementation of readily available psychology/psychiatric services, in community, outpatient and inpatient settings, to recognize, address and manage patients with behaviors concerning for potential insulin overdoses.