(262) ​Role of Early Administration of Glucocorticoids in Insulin Overdose

Introduction: Massive insulin overdose can cause severe hypoglycemia that may be refractory to standard treatment options. Here, we present a case of mixed long-acting and short-acting insulin overdose with severe refractory hypoglycemia to maintenance dextrose fluid, rescue dextrose boluses, oral supplementation, octreotide drip, and subsequent improvement after use of intravenous hydrocortisone.

Description: A 46-year-old male with a past medical history of alcoholic cirrhosis and type 2 diabetes mellitus presented to the hospital 12 hours after self administration of 300 units of insulin aspart and 300 units of insulin glargine in an attempt to suicide. On presentation, he was hemodynamically stable with blood work was significant for blood glucose of 31, potassium of 3.4. He was admitted to the intensive care unit and initiated on D10NSS at 150 ml/hr, octreotide 50 mcg bolus followed by 50 mcg/hr. After 6 hours, octreotide was discontinued due to lack of apparent efficacy with continued hypoglycemic blood sugar levels. The patient’s blood glucose remained persistently less than 70 with 14 finger sticks showing BG less than 40 every 30 mins requiring 16 boluses of 25g dextrose 50%. After 12 hours, given persistent hypoglycemia, the patient was initiated on intravenous hydrocortisone 100 mg every 8 hours. After administration of two doses of hydrocortisone, there was a marked improvement and no further rescue boluses of dextrose 50% were required for the remainder of the hospitalization. Upon resolution of the patient's hypoglycemia for more than five hours, he was transferred to a step-down unit with eventual down-titration and discontinuation of all dextrose containing maintenance fluids and hydrocortisone.

Discussion: Management of refractory hypoglycemia in insulin overdose can be challenging due to risks of fluid overload and the need for frequent administration of rescue dextrose boluses. Hydrocortisone helps in insulin overdose by increasing hepatic, extrahepatic gluconeogenesis especially evident in our patient with liver cirrhosis and by decreasing the uptake of glucose by peripheral tissues. This beneficial mechanism along with the overall tolerability of a short course of therapy proves a potentially favorable option for treatment of refractory hypoglycemia due to insulin overdose.