Role of Steroids in Refractory Hypoglycemia Due to An Overdose of 10,000 Units of Insulin Glargine: A Case Report and Literature Review

Critical Low Catastrophe: A Case Report of Treatment-Refractory Hypoglycemia following Overdose of Long-Acting Insulin

“…Excision of the insulin depot was not possible in our patient because she did not have a clear site of fluctuance at the injection site. Consistent with use of hydrocortisone in a previous case report [ 14 ], a trial of stress-dose hydrocortisone was started. Hydrocortisone was chosen due to its shorter duration of action compared to other glucocorticoids, thereby reducing the risk of subsequent hyperglycemia.…”

“…In cases where hypoglycemia persists despite standard treatment modalities, other treatment options can be explored. The somatostatin analog octreotide has been tried in previous cases of insulin overdose [ 13 , 14 ]. However, its use was associated with inconsistent results and is usually reserved for hypoglycemia secondary to sulfonylurea use [ 15 ].…”

“…Hence, glucocorticoids may serve as an adjunctive therapy option in managing refractory hypoglycemia in cases of insulin overdose. This approach has been utilized in a prior case of refractory hypoglycemia associated with insulin overdose where hydrocortisone was administered to prevent volume overload associated with the infusion of large volumes of dextrose-containing IV fluids [ 14 ]. Early initiation of steroids in cases with persistent hypoglycemia may reduce the duration of intensive care unit stay, avoid invasive procedures like central line placement for 25% or 50% dextrose infusions, and prevent volume overload from large volume dextrose infusions [ 18 ].…”

“…In the setting of persistent hypoglycemia three days after the reported overdose and concern for volume overload, other treatment modalities were considered. Octreotide was not given due to the inconsistent results from previous cases along with its high cost and because sulfonylurea coingestion was not suspected [ 13 , 14 ]. Excision of the insulin depot was not possible in our patient because she did not have a clear site of fluctuance at the injection site.…”

“…However, given the delay in the administration of hydrocortisone until three days after presentation, it is also possible that the hypoglycemia resolved due to the clearance of the exogenous insulin, as opposed to the effect of glucocorticoid administration. Finally, while the efficacy of IV glucagon infusion is more established in pediatrics with T1DM and in neonatal hypoglycemia, the efficacy of continuous infusions of IV glucagon for the treatment of insulin-induced hypoglycemia in adults is unclear given the absence of strong supporting evidence in this population [ 14 , 20 , 21 ]. Glucagon acts by promoting glycogenolysis and gluconeogenesis and thus has limited use once glycogen stores have been depleted.…”