Endocrine Abstracts

Intentional insulin overdose in diabetic patients is a rare critical situation. The severity is due to numerous neurological complications, electrolyte disturbances, liver and lung damage or death. A 59-year old female, under treatment for depressive disorder, diagnosed with type 2 diabetes since 2016 and treated with glargine (20 IU/day), lispro (30 IU/day) insulin and Metformin (500 mg/day) was admitted to the Internal Medicine department via ER (emergency room) for repetitive episodes of severe hypoglycemia in the ER after administration of 280IU of glargine insulin. Found unconscious, dyspneic with a glycemic value (Gl) of 26 mg/dl, she was brought to the ER approximately 9 hours after overdose with a Gl of 97 mg/dl after 70 ml of 33% glucose. At admission: altered general status, Gl=130 mg/dl, BP=160/90 and QT prolongation. Labs exams revealed: Gl=35.46 mg/dl, hyperamylasemia, hypokalemia and A1c=5.96%. An infusion of 5% glucose was begun at 250 ml/h. The glucose infusion rhythm and concentration was adjusted according to the glycemic profile while trying to maintain values around 150 mg/dl. Hypokalemia was corrected by oral supplementation. Calcium and magnesium remained within normal limits during hospitalization but phosphorus could not be determined. Psychological and psychiatric consults revealed the trigger of the overdose (a health problem of a newborn grandson) and recommended hospitalization in a psychiatric facility, but the patient refused. The last hypoglycemic episode (Gl=62 mg/dl) was registered 24h after admission. In the 4th day of hospitalization, the oral treatment with Metformin was resumed and she was discharged in the 5th day with only metformin and glargine insulin. Insulin overdose requires intensive and prolonged glycemic monitoring to prevent recurrent hypoglycemia due to an early cessation of i.v. therapy. The dose is not correlated with the severity of hypoglycemia but with a prolonged hypoglycemic risk higher than that deduced from the pharmacokinetics of insulin analogue administered. This case represents the first insulin overdose treated in our hospital.