(954) Octreotide for Refractory Hypoglycemia

Introduction: Management of hypoglycemia within the intensive care unit (ICU) is a fundamental component of patient care and can have a significant impact on mortality. We describe a case of refractory hypoglycemia where treatment with subcutaneous octreotide improved glucose control and eliminated dependence upon a continuous infusion of dextrose.

Description: A 35-year-old male with a history of alcohol use disorder complicated by alcoholic hepatitis and acute liver failure, presented to the emergency department (ED) with significant weakness, fatigue and difficulty walking, found to have severe hypokalemia, renal failure and worsening liver failure requiring ICU admission. Labs on admission were significant for a glucose value of less than 20 mg/dL, AST of 242 and ALT of 101 along with a total bilirubin elevated to 37.5 mg/dL. Hospital course was complicated by refractory hypoglycemia with glucose as low as 28 mg/dL despite a continuous infusion of dextrose 10% at a rate of 200 mL/hr. After an additional 48 hours of dextrose 12.5% at a rate of 200 mL/hr, glucose remained in the low 100s with episodes of hypoglycemia down to 58 mg/dL. Given the dependence upon a continuous infusion of dextrose to maintain normoglycemia, a recommendation was made to start subcutaneous (SubQ) octreotide 100 mcg every 8 hours to facilitate weaning off the dextrose infusion and prevent significant volume overload. After receiving a dose of octreotide 100 mcg SubQ, the patient was able to be successfully weaned off dextrose 4 hours later. By day 4, glucose was maintained in the 150s on the current regimen of octreotide 100 mcg SubQ every 8 hours, without the need for supplemental dextrose boluses.

Discussion: Octreotide is a somatostatin analog that binds to G protein-coupled somatostatin-2 receptors in pancreatic beta-cells, leading to decreased calcium influx and inhibition of insulin secretion from the pancreas. Few studies have described it’s use in cirrhosis-induced hypoglycemia where fibrosis and impairment of hepatic parenchyma leads to decreased glycogenolysis, gluconeogenesis, and glucose output. This case report highlights the utility of octreotide for treatment of refractory hypoglycemia in a cirrhotic patient with impaired gluconeogenesis unable to be regulated by exogenous administration of dextrose alone.