Attempted suicide by insulin injection treated with artificial pancreas.
Gin H,Larnaudie B,Aubertin J
British medical journal (Clinical research ed.)
An elderly woman with longstanding insulin dependent diabetes tried to commit suicide by injecting 400 units of insulin subcutaneously (usual total daily dose 56 units). She was admitted to hospital within the hour and treated with the aid of an artificial pancreas. This avoided the usual difficulty of the physician having to cope with rapid and substantial fluctuations in blood glucose concentrations and 67 hours after the overdose insulin was reinstituted. Using an artificial pancreas in insulin overdose is an important advance in management and may avoid the need for surgical intervention such as excising the site of injection.
Emergency presentation of an elderly female patient with profound hypoglycaemia.
Waring W S,Alexander W D
Scottish medical journal
We present the case of an elderly non-diabetic female who was admitted to hospital as an emergency due to loss of consciousness. Her clinical presentation was consistent with hypoglycaemia due to a massive insulin overdose. However, the patient refuted the possibility of insulin administration, and the circumstances were reported to the police for investigation. This case demonstrates the clinical and biochemical characteristics of insulin overdose. Furthermore, it serves to illustrate the sequence of events that may be created when foul play is suspected, and the factors related to patient confidentiality that require consideration by the responsible physician.
Estimated glucose requirement following massive insulin overdose in a patient with type 1 diabetes.
Fasching P,Roden M,Stühlinger H G,Kurzemann S,Zeiner A,Waldhäusl W,Laggner A N
Diabetic medicine : a journal of the British Diabetic Association
A well-documented case of a 35-year-old male Type 1 diabetic patient who was admitted as an emergency after having injected 1500 international units (IU) of insulin (750 IU regular insulin,750 IU NPH-insulin) subcutaneously as a suicidal attempt is reported. Computing disappearance rates of glucose from its infused amounts necessary to maintain euglycaemia during 65 h after the insulin injection in analogy to experimental hyperinsulinaemic euglycaemic clamp examinations, a glucose consumption of 55.6 mumol kg-1 min-1 was found at peak serum insulin concentrations of about 14,400 pmol l-1. The insulin-induced glucose dynamics resemble closely those seen in healthy persons and Type 1 diabetic subjects during a 10 mU kg-1 min-1 euglycaemic clamp. This information may be useful in the handling of similar cases of insulin intoxication.
Attempted suicide by insulin overdose in insulin-requiring diabetics.
Martin F I,Hansen N,Warne G L
The Medical journal of Australia
Four cases of suicidal insulin overdose in insulin-requiring diabetics presented to one hospital in three years. In three cases there was a history of depression; but despite huge doses of insulin (3,000 and 1,500 units) in two, no patient died and only one had residual signs of clinical brain damage. The estimated plasma insulin level was not well correlated with the severity of the hypoglycaemia. It is probable that suicidal insulin overdose is more common than reports in the literature suggest, and may often be unrecognized. The dissociation between huge doses of insulin and the severity of the subsequent hypoglycaemia in diabetics is unexplained.
Insulin overdose in eight patients: insulin pharmacokinetics and review of the literature.
Arem R,Zoghbi W
Eight patients are reported who attempted suicide by self-administering insulin. Review of the literature reveals that most patients who attempt suicide in this manner are insulin-requiring diabetics, and depression or another psychiatric illness is recognized in the majority. The amount of insulin used varied from 20 units to 3200 units. The duration of the hypoglycemic effect that may be as long as several days, seems to correlate with the dose and type of insulin administered, and may be determined predominantly by the slow release of insulin from the injection site. Recurrence of insulin overdose has been frequently documented. The adult respiratory distress syndrome, not previously described in patients with insulin overdose, occurred in two of our cases, and various mechanisms for this complication are considered. Serious neurologic sequelae and death may be related to delay in therapy, and glucose requirements appear to be higher during the first 24 hours of therapy. Insulin overdose with suicidal intent may be more common than generally thought and should be considered in diabetic patients with severe unexplained hypoglycemia.
[Postmortem diagnosis of exogenous insulin administration].
Logemann E,Pollak S,Khalaf A N,Petersen K G
Archiv fur Kriminologie
Toxicological analyses are presented in connection with the decrease of a 51-year-old female medical practitioner. The woman was found dead in a woodland about 250 metres far from her motor car. According to her relatives the woman had expressed her intention to commit suicide. Two single use syringes, two empty (300 units) cartridges intermediate type human insulin, and one empty ampoule of 10 mg diazepam were found near the corpse. The toxicological analyses of the heart-blood resulted in 210 ng diazepam/ml, 382 mu units/ml insulin and 0.58 ng/ml C-peptide. After extraction of a tissue sample from the injection area (cubital region) 113 milliunits insulin could be detected by radioimmunoassay. The insulin concentration in relation to the C-peptide concentration in the blood of the corpse indicated an exogenous supply of insulin. The HbA1c and fructosamine data in the blood and the histological examination of the pancreas showed that the woman had not suffered from diabetes.
Insulin poisoning with suicidal intent.
Gundgurthi Abhay,Kharb Sandeep,Dutta M K,Pakhetra R,Garg M K
Indian journal of endocrinology and metabolism
We report a 27-year-old paramedical lady with no known comorbidities, who presented with rapid-onset coma with hypoglycemia (plasma glucose at admission was 35 mg/dL). Clinical alertness suspected and confirmed the diagnosis of exogenous insulin administration probably with suicidal intent. During the course of her ICU stay, she developed bradycardia and hypotension which required ionotropic support. She remained in coma for 90 hours. A total of 470 g of dextrose was infused until she regained consciousness. No other complications of insulin overdose were observed during her stay in the hospital. Recovery was complete without any residual neurological deficits. Insulin administration should be kept in differential diagnosis when any case presents with coma and hypoglycemia, especially in paramedical personnel.
Massive insulin overdose: detailed studies of free insulin levels and glucose requirements.
Samuels M H,Eckel R H
Journal of toxicology. Clinical toxicology
The course of a diabetic patient who self-administered 2500 U of NPH insulin subcutaneously was examined in detail. Despite resumption of oral intake on day 3, she required iv glucose for 6 days, during which time serum free insulin levels remained elevated. Glucose requirements closely matched those calculated from published euglycemic clamp data on maximal glucose disposal rates during insulin infusion. We postulate that her prolonged course was due to delayed absorption of the subcutaneous insulin. This is the first case of massive insulin overdose studied in such detail, and the results may facilitate management of future cases.
Intentional massive insulin overdose: recognition and management.
Roberge R J,Martin T G,Delbridge T R
Annals of emergency medicine
A case of intentional massive insulin overdose requiring prolonged glycemic support is presented. Suicidal insulin overdose may be more common than generally appreciated. Because hypoglycemic reactions are evaluated routinely in the ED, emergency physicians should maintain a high degree of suspicion regarding suicidal intent or foul play in diabetics with hypoglycemia who respond minimally to the administration of concentrated glucose solutions or in hypoglycemic presentations by nondiabetics who have access to diabetic medications. Fingerstick glucose evaluations or serum glucose levels should be obtained routinely at 15 to 30 minutes after glucose administration in any hypoglycemic patient to gauge the intensity of glucose use. Inability to maintain euglycemia following glucose administration suggests excessive insulin and requires further workup. Evaluation of serum insulin and C-peptide levels is useful in confirming intentional overdoses in cases that are not clear-cut. Glucose infusion rates must be tailored individually to each overdose situation as great individual variability exists in insulin absorption and effects. The clinician should anticipate the possible need for prolonged glycemic support in this setting.
Life-threatening hypoglycemia associated with intentional insulin ingestion.
Svingos Robert S,Fernandez Erica M,Reeder Don N,Parker John J
There are reports of insulin overdose by injection, yet little is known regarding the potential harms of intentional oral ingestion of insulin. In this report, we describe a case of massive insulin ingestion and ensuing hypoglycemia. To our knowledge, there are no previously published cases of hypoglycemia caused by intentional insulin ingestion. A 51-year-old man intentionally ingested three 10-ml vials (total of 3000 units) of various insulins: one vial each of insulin aspart, lispro, and glargine. Four symptomatic hypoglycemic episodes, with blood glucose levels of 48, 25, 34, and 40 mg/dl, occurred approximately 1, 3, 4, and 5 hours, respectively, after ingestion. The hypoglycemia could not be explained other than the ingestion of the insulins. The patient was admitted for observation, and euglycemia occurred within 24 hours without any additional hypoglycemic episodes. Hypoglycemia treatment is reviewed in this case report, and factors that may affect systemic response of orally ingested insulin, including gastrointestinal absorption and insulin sensitivity, are discussed. In addition, the findings of our case report may provide useful insight into the development of novel oral insulin products that are currently in research. Despite poor bioavailability (1%) when taken orally, insulin may produce symptomatic hypoglycemia with a massive ingestion. Vigilant blood glucose monitoring, supportive care with glucose replacement therapy, and admission to the hospital for observation may be required.
[A suicide by insulin injection--case report].
Nikolić Slobodan,Atanasijević Tatjana,Popović Vesna
Srpski arhiv za celokupno lekarstvo
Suicide by injection of insulin overdose is uncommon. Insulin has been used as an agent for suicide both in diabetics and healthy subjects. The methods of postmortem forensic diagnosis of insulin overdose were reviewed. Police investigation could be crucial to document the amount and type of insulin used. In addition, the complete forensic autopsy, microscopic analysis of tissue samples, consecutive chemical-toxicological investigation and appropriate laboratory tests are required to make proper diagnosis in these cases. To assess pre-mortem hypoglycemic state at the time of dying, it is necessary to establish postmortal concentrations of glucose, lactate and potassium in vitreous humor. Since the use of insulin for medical treatment, only two cases with diagnosis of suicidal insulin overdose were confirmed at the Institute of Forensic Medicine in Belgrade. In this paper, the authors present one such case. An 84-year-old male was found dead in his flat. He had diabetes mellitus during the last fifty years, and he used insulin twenty years. A few empty insulin ampullae and plastic syringes were found nearby deceased, on the room-table during the crime scene investigation, as well as his suicidal note. The forensic autopsy, microscopic, chemical-toxicological and biochemical analyses of tissue and body-liquid samples as well as police investigation indicated suicide due to insulin-overdose.
Suicidal insulin overdose in a type 1 diabetic patient: relation of serum insulin concentrations to the duration of hypoglycemia.
Shibutani Y,Ogawa C
Journal of diabetes and its complications
We present a case of a 31-year-old Type 1 diabetic woman who self-administered 2400 units of insulin mixture (70% NPH human insulin and 30% Regular human insulin) as a suicidal attempt. The subsequent hypoglycemia was prolonged probably due to delayed absorption of the subcutaneous insulin, but it was not very difficult to control despite the administration of large amounts of insulin. Although the estimated serum insulin level was not well correlated with the severity of hypoglycemia, the hypoglycemia subsided when the serum insulin level returned to the physiological level. Therefore, the study of insulin pharmacokinetics after insulin overdose may be useful to know the necessary duration of exogenous glucose administration required to manage the medical emergency of severe insulin intoxication in future cases.
Peripheral IV Insulin Infusion Infiltration Presenting as "Insulin Resistance".
Kim Tiffany Y,Woeber Kenneth A,MacMaster Heidimarie Windham,Rushakoff Robert J
Critical care medicine
OBJECTIVES:We present the case of a 66-year-old woman who developed hypoglycemia following the prolonged infiltration of a high dose continuous peripheral IV insulin infusion. STUDY SELECTION:Case report. DATA SOURCES AND EXTRACTION:PubMed was searched for relevant literature on exogenous hyperinsulinemic hypoglycemia. DATA SYNTHESIS:The patient was postlung transplantation and was receiving high doses of glucocorticoids. Despite increasing the peripheral IV insulin rate, hyperglycemia persisted. We discovered that the IV insulin infusion line infiltrated, resulting in a large subcutaneous insulin depot, estimated to be 450 units of regular insulin. She subsequently experienced prolonged hypoglycemia that was managed with concentrated dextrose containing fluids. In our literature search, there were no similar case reports. The literature on insulin overdose, usually from suicide attempts, can help guide the management of iatrogenic hyperinsulinemic hypoglycemia. Important management considerations include anticipated duration of hypoglycemia, supplemental glucose, fluid management, and electrolyte monitoring. CONCLUSION:Peripheral IV insulin infusion infiltration should be considered when patients do not respond to increasing rates of insulin infusion.
[Alleged suicide by insulin].
Birngruber Christoph G,Krüll Ralf,Dettmeyer Reinhard,Verhoff Marcel A
Archiv fur Kriminologie
A 26-year-old man, who was on probation, was found dead in his home by his mother. Insulin vials and 2 insulin pens, which the man's stepfather (an insulin-dependent diabetic) had been missing for over a week, were found next to the deceased. The circumstances suggested suicide by an injected insulin overdose. At the time of the autopsy, the corpse showed already marked signs of autolysis. Clinical chemical tests confirmed the injection of insulin, but indicated hyperglycemia at the time of death. Toxicological analyses revealed that the man had consumed amphetamine, cannabinoids, and tramadol in the recent past. Histological examination finally revealed extensive bronchopneumonia as the cause of death. The most plausible explanation for the results of the autopsy and the additional examinations was an injection of insulin as a failed attempt of self-treatment. It is conceivable that the man had discovered by a rapid test that he was a diabetic, but had decided not to go to a doctor to avoid disclosure of parole violation due to continued drug abuse. He may have misinterpreted the symptoms caused by his worsening bronchitis and the developing bronchopneumonia as symptoms of a diabetic metabolic status and may have felt compelled to treat himself with insulin.
Insulin glargine overdose.
Doğan Fatma Sarı,Onur Ozge Ecmel,Altınok Arzu Denizbaşı,Göneysel Ozlem
Journal of pharmacology & pharmacotherapeutics
Insulin glargine is a long acting novel recombinant human insulin analogue indicated to improve glycemic control, in adults and children with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus. The time course of action of insulins including insulin glargine may vary between individuals and/or within the same individual. Insulin glargine is given as a 24-h dosing regimen and has no documented half-life or peak effect. Hypoglycemia is the most common adverse effect of insulin, including insulin glargine. As with all insulins, the timing of hypoglycemia may differ among various insulin formulations. We present a case of a 76-year-old male insulin-dependent diabetic patient with refractory hypoglycemia secondary to an intentional overdose of insulin glargine. We would like to highlight the necessity of prolonging IV glucose infusion, for a much longer period than expected from pharmacokinetic properties of these insulin analogues after intentional massive overdose.
Electrolyte disorders following massive insulin overdose in a patient with type 2 diabetes.
Matsumura M,Nakashima A,Tofuku Y
Internal medicine (Tokyo, Japan)
We present a case of a 47-year-old man with Type 2 diabetes mellitus who attempted suicide with 2,100 U of insulin injected subcutaneously. Administration of dextrose intravenously was required to maintain the blood glucose concentration normally for 5 days. Moreover, hypokalemia, hypophosphatemia, and hypomagnesemia were also seen for 24 hours after insulin injection. The serum phosphorus and magnesium concentrations decreased to nadirs of 1.6 mg/dl and 1.6 mg/dl respectively 7 hours after insulin injection. Electrolyte disorders other than hypokalemia may be induced in hypoglycemic patients by massive insulin overdose.
Suicide via insulin overdose in nondiabetics: the New Mexico experience.
Winston D C
The American journal of forensic medicine and pathology
Four cases of self-injected insulin overdose in nondiabetic individuals are presented. Included are two cases of presumed insulin overdose (no autopsy), one case with elevated vitreous insulin (autopsy), and one case with elevated postmortem blood insulin and low blood C peptide (autopsy). These cases demonstrate the need for a thorough scene investigation, complete autopsy, and proper collection and storage of specimens to certify a death caused by insulin intoxication as well as to determine the manner of death. Appropriate collection and preservation of postmortem blood samples are discussed.
Attempted suicide by massive insulin injection: a case report and review of the literature.
Thewjitcharoen Yotsapon,Lekpittaya Nampetch,Himathongkam Thep
Journal of the Medical Association of Thailand = Chotmaihet thangphaet
The authors present a case of an 80-year-old man, non-diabetic, who attempted suicide by injecting himself subcutaneously with 10,000 units of Humulin R and 6000 units of Humulin N. Administration of dextrose intravenously was required for 13 days to maintain the capillary blood glucose within the range of 100-180 mg/dl. Hyponatremia, hypokalemia, hypophosphatemia, and elevated liver enzymes were also seen after massive insulin injection. Glucose requirement index was established to demonstrate the trend of glucose requirement during hospitalization. He recovered completely without any complication after monitoring blood glucose and titrating intravenous glucose carefully for two weeks. Current literature about how to manage insulin overdose was reviewed in the present article.
Acute pulmonary edema caused by hypoglycemia due to insulin overdose.
Uchida Daigaku,Ohigashi Sawako,Hikita Satosi,Kitamura Nobuya,Motoyoshi Mitsutaka,Tatsuno Ichiro
Internal medicine (Tokyo, Japan)
We report a very rare case of acute pulmonary edema caused by hypoglycemia from insulin overdose during an attempted suicide. A 16-year-old woman with type 1 diabetes was brought to our hospital because of hypoglycemic coma. She exhibited severe hypoxia; upon intubation, bloody froth poured out of the tube. Chest X-ray revealed bilateral infiltrates. Endocrinological data revealed high concentrations of catecholamines. This case indicates that pulmonary edema remains a potential complication of insulin overdose. The possible mechanisms of pulmonary edema associated with hypoglycemia are discussed.
Intravenous overdose of insulin glargine without prolonged hypoglycemic effects.
Thornton Stephen,Gutovitz Scott
The Journal of emergency medicine
BACKGROUND:Insulin glargine is a long-acting insulin that can cause prolonged hypoglycemia when misdosed or overdosed subcutaneously. There are no reports of intravenous overdoses of insulin glargine. OBJECTIVES:We present a case of a patient inadvertently given a large intravenous dose of insulin glargine (100 units) who had an unremarkable course. CASE REPORT:A 46-year-old woman with a history of type 2 diabetes was found to be hyperglycemic and was mistakenly given an intravenous bolus of 100 units of insulin glargine. She did not become hypoglycemic, did not require parenteral dextrose, and her blood sugar readings stabilized within 3 h. She was admitted and observed for 17 h and discharged without complication. CONCLUSION:To our knowledge, this is the first report of a significant intravenous insulin glargine administration. This patient had an unremarkable course and recovered without any parenteral glucose. This case, along with prior studies on healthy volunteers, suggests that unlike subcutaneous overdoses, intravenous insulin glargine misdose/overdose may not need prolonged observation; an observation time of 6 h may be sufficient in these patients.
Prolonged glucose requirements after intentional glargine and aspart overdose.
Fromont I,Benhaim D,Ottomani A,Valéro R,Molines L,Vialettes B
Diabetes & metabolism
Intentional insulin overdose in diabetic patients is a rather rare critical situation. We report the case of a patient suffering from type 1 diabetes who was found comatose with a plasma glucose close to zero after having injected herself massive doses of both aspart and glargine insulin analogues. The prevention of hypoglycaemic episodes in this patient required a long-term glucose infusion (i.e., 59 hours) which significantly exceeds the usual time-effect profile of glargine. This observation emphasizes again that clinicians should be aware of the extremely prolonged action of long acting insulin analogue glargine after intentional massive injection in order to avoid a too early interruption of glucose infusion and a subsequent risk of relapse of severe hypoglycaemic episodes.
Prolonged hypoglycaemia after insulin lispro overdose.
Brvar Miran,Mozina Martin,Bunc Matjaz
European journal of emergency medicine : official journal of the European Society for Emergency Medicine
Insulin lispro has a more rapid onset and a shorter duration of hypoglycaemic action than regular insulin. We report a 39-year-old woman, with no previous medical history, who injected 300 U of the insulin lispro (Humalog) in an attempted suicide. Half an hour later, she was found comatose and brought to our emergency department. On arrival, she was comatose, with capillary glucose of 0.4 mmol/L. She awoke after a 50 ml intravenous bolus of 50% glucose. A continuous infusion of 10% glucose was started. Intermittent hypoglycaemia with neurological signs requiring treatment with 50% glucose was recorded three times during subsequent hospitalization, the last episode being 11 h after insulin injection. The plasma insulin level 4 h after injection was 1465 mU/L, and 18 h after injection was 11 mU/L. Hypoglycaemia after an insulin lispro overdose may last for more than 11 h. Repeated hypoglycaemia after an insulin overdose could be avoided with a glucose infusion rate equivalent to the maximal glucose disposal rate.
[Non-fatal hyperkalemia in lactic acidosis due to metformin overdose. Report of one case].
Díaz Rienzi,Vega Jorge,Goecke Helmuth
Revista medica de Chile
We report a 74-year-old man with diabetes mellitus type 2 and hypertension, who recently underwent coronary bypass surgery due to severe triple vessel disease receiving cardiological and combined antidiabetic therapy, including metformin 4 g/day. He was admitted with abdominal pain, nausea, vomiting, diarrhea and loss of consciousness. At admission, he was disoriented and agitated with signs of poor perfusion. His blood pressure was 80/70 mmHg, pulse rate 40 beats/min, respiratory rate 20-breaths/min, and axillary temperature 35 °C. Biochemical profile revealed an extreme hyperkalemia of 15.4 mEq/L (double checked), elevated creatinine, uremia and brain natriuretic peptide; hypoglycemia (blood glucose 68 mg/dl) and normal C Reactive Protein. Arterial blood gases revealed severe lactic acidemia. The electrocardiogram showed sinus bradycardia, simple AV block, widened QRS with prominent T wave and prolonged QT. He was admitted to the Intensive Care Unit (ICU) with the suspicion of lactic acidosis associated with metformin, receiving fluid management, intravenous hypertonic glucose plus insulin and sodium bicarbonate, mechanical ventilation, vasopressor therapy, a temporary pacemaker lead, in addition to continuous venovenous hemodiafiltration. Two days later, the patient experienced a significant clinical improvement with normalization of the acid-base status, plasma lactate and potassium levels. On day 9, diuresis was recovered, creatinine and uremia returned to normal levels and the patient was discharged from the ICU.
Accidental insulin overdose.
Batalis Nick I,Prahlow Joseph A
Journal of forensic sciences
Exogenous insulin has been used for many years to treat diabetes mellitus. Due to the complex nature of insulin therapy, there have been numerous accidental overdoses by these patients. Unfortunately, in other instances, insulin has been used as an agent for suicide and homicide in diabetics as well as nondiabetics. Presented here is a fatal case of accidental insulin overdose in a nondiabetic. Following the case presentation, we review insulin pharmacology and the methods of diagnosing insulin overdose postmortem. In any case of insulin overdose, a comprehensive scene investigation to document the amount and type of insulin used, along with information revealing the source of the insulin is critical. In addition, a complete autopsy, including appropriate laboratory studies, is needed to make a diagnosis in these cases. Proper attention should be given to collection and storage of blood samples, as these specimens often yield the strongest evidence of insulin overdose.
[Research Progress of the Death Caused by Insulin Intoxication].
Chen L,Lu Y X
Fa yi xue za zhi
In recent years, with the sustained increase of the incidence of diabetes in humans and the wider use of exogenous insulin, the cases of inappropriate use and overdose of insulin is growing, even the cases of suicide and homicide using insulin. Through searching the literature at home and abroad about the mechanism, clinical and case report of poisoning and death caused by insulin intoxication, this paper reviews the mechanism, clinical manifestations, pathological changes, and forensic examination.
Intentional overdose with insulin glargine and insulin aspart.
Tofade Toyin S,Liles E Allen
Reports of intentional massive overdoses of insulin are infrequent. A review of the literature revealed no reports of overdose attempts with either insulin glargine or insulin aspart. We report the case of a 33-year-old woman without diabetes mellitus who intentionally injected herself with an overdose of both products, which belonged to her husband. She arrived at the emergency department 15 hours after her suicide attempt, which took place the night before. Her husband had checked her blood glucose level throughout the night and had given her high-carbohydrate drinks and foods. The patient had a history of obsessive-compulsive disorder, major depression, and numerous suicide attempts. She recovered from the resulting hypoglycemia after 40 hours of dextrose infusion and was transferred to a mental health facility. The main danger associated with insulin overdose is the resultant hypoglycemia and its effects on the central nervous system; hypokalemia, hypophosphatemia, and hypomagnesemia also can develop with excess insulin administration. Dextrose infusion, with liberal oral intake when possible, and monitoring for electrolyte changes, making adjustments as needed, are recommended for the treatment of intentional insulin overdose.
[A 45-fold liraglutide overdose did not cause hypoglycaemia].
Madsen Lene Ring,Christiansen Jens Juel
Ugeskrift for laeger
Glucagon-like peptide (GLP)-1 analogues such as liraglutide have gained popularity in the treatment of type 2 diabetes over the last years. By mimicking the effects of the native GLP-1, it enhances the glucose-dependent secretion of insulin, suppresses elevated glucagon secretion, increases satiety and slows down gastric emptying. Because of its ways of action it is not likely to cause hypoglycaemia in cases of overdosage. We present a 45-fold overdose of liraglutide (confirmed by P-liraglutide measurements) leading to nausea and vomiting, but no hypoglycaemia and no sign of pancreatitis.
Suicide attempt by an overdose of sitagliptin, an oral hypoglycemic agent: a case report and a review of the literature.
Furukawa Shinya,Kumagi Teru,Miyake Teruki,Ueda Teruhisa,Niiya Tetsuji,Nishino Keiichiro,Murakami Shigeto,Murakami Masato,Matsuura Bunzo,Onji Morikazu
Dipeptidyl peptidase-4 (DPP-4) inhibitors are a newer class of oral hypoglycemic agents for the management of diabetes that elevate the plasma concentration of active glucagon-like peptide-1 via inhibition of DPP-4. They effectively lower not only glycosylated hemoglobin levels, but also fasting and postprandial plasma glucose levels. Patients with diabetes occasionally consume an overdose of oral hypoglycemic agents in suicide attempts: the prevalence of depression is high in patients with diabetes, and depression is a strong risk factor for suicide. We encountered an 86-year-old woman with type 2 diabetes and depression, who was transferred to the emergency room 4h after ingestion of 1,700 mg of the DPP-4 inhibitor sitagliptin (1,700 mg is 17 times greater than the approved maximum dose). Upon arrival, she was fully conscious, plasma glucose was 124 mg/dL, and serum immunoreactive insulin level was 5.81 µU/mL. Thereafter, the plasma concentration of sitagliptin rose to 3,793 nM, which is 4.5 times higher than the value found under regular treatment with the maximum dose. The patient did not suffer from hypoglycemia, suggesting that a single oral overdose of sitagliptin is unlikely to cause hypoglycemia. A literature review of oral anti-diabetic agents revealed that overdose of biguanides is occasionally fatal when immediate intensive care is not provided. In summary, sitagliptin is a good treatment option for diabetic elderly patients or patients with psychiatric disorders who are suicidal and do not require insulin.
Suicide by combined insulin and glipizide overdose in a non-insulin dependent diabetes mellitus physician: a case report.
Rao Nageshkumar G,Menezes Ritesh G,Nagesh K R,Kamath Ganesh S
Medicine, science, and the law
A case of self-injected insulin intoxication with an oral hypoglycaemic agent glipizide overdose in a type-II/non-insulin dependent diabetes mellitus (NIDDM) individual, a physician by profession, is presented with a review of the literature. The case demonstrates the need for thorough scene investigation, perusal of clinical details and complete autopsy to certify the death caused by combined insulin and glipizide overdose, and the manner of death. A meticulous search in the English literature reveals that hardly any fatal cases of combined insulin and glipizide overdose have been reported, with almost no cases from India, thus making this case report relevant and unique.
Fatal Insulin Overdoses: Case Report and Update on Testing Methodology.
Sunderland Nick,Wong Sophia,Lee Carol K
Journal of forensic sciences
Suicidal insulin overdoses are an under-recognized and uncommon cause of death, often relying on scene and nonspecific autopsy findings. Here, we present a case report of a fatal exogenous insulin overdose in a patient with type 1 diabetes. In our case, there were no contributory autopsy findings; however, serum analog aspart insulin levels were c. 10× the predicted therapeutic upper limit (4000, reference 6.6-55 uU/mL), which correlated with scene findings. This was specifically determined by a newly developed immunocapture liquid chromatography-tandem mass spectrometry assay, able to discriminate between various synthetic insulin analogs. Total insulin levels by immunoassay were highly elevated on the Siemens Advia Centaur, but not the Roche platforms (4741 vs. 5.2 uU/mL, respectively), showing variable sensitivity of detection within the same analog depending on assay. We discuss the prevalence and features to look for at autopsy in these types of cases. Additionally, analytical options for testing insulin levels, including new methodologies, guidance on collection of samples, as well as an outline of available historical reference range data are discussed.
Acute hepatic injury following treatment of a long-acting insulin analogue overdose necessitating urgent insulin depot excision.
Warriner D,Debono M,Gandhi R A,Chong E,Creagh F
Diabetic medicine : a journal of the British Diabetic Association
BACKGROUND:A 26-year-old man with Type 1 diabetes presented with an overdose of 4800 units of the long-acting insulin analogue, glargine (Lantus). Glucose supplementation of approximately 800 g/day was associated with acute hepatic injury. METHODS:On day 4, a depot of insulin was excised from the patient's abdominal wall; this was followed by a reduction in his glucose requirements and improvement in liver function. CONCLUSIONS:This report highlights the risk of acute hepatic injury during the treatment of insulin overdose and the importance of careful glucose supplementation. It also demonstrates how earlier excision of an insulin depot could potentially prevent this problem and hasten recovery.
Problem based review: the patient who has taken an overdose of long-acting insulin analogue.
Eldred A E,Mustafa O G,Hunt K F,Whitelaw B C
Insulin overdose can cause harm due to hypoglycaemia, effects on electrolytes and acute hepatic injury. The established long-acting insulin analogue preparations (detemir and glargine) can present specific management problems because, in overdose, their effects are extremely prolonged, often lasting 48-96 hours. The primary treatment is continuous intravenous 10% or 20% glucose infusion with frequent capillary blood glucose monitoring. Surgical excision of the insulin injection site has been used successfully, even days after the overdose occurred. Once the effects of overdose have receded, diabetes treatment must be restarted with care, especially in patients with type 1 diabetes. Monitoring serum insulin concentration has been successfully used to predict when the effects of the overdose will cease.
Lantus insulin overdose: a case report.
Lu Michael,Inboriboon Pholaphat Charles
The Journal of emergency medicine
BACKGROUND:Insulin glargine is a relatively new medication in the treatment of diabetes mellitus, and there have only been six case reports of overdoses in the literature with this specific insulin. OBJECTIVES:We present a unique case of insulin glargine overdose that presented with persistent hypoglycemia and required prolonged in-hospital treatment. CASE REPORT:A 51-year-old woman with insulin-dependent diabetes and a history of suicide attempts by medication overdose presented to the Emergency Department the morning after she had self-administered 2700 units of her insulin glargine in an attempted suicide. She was treated with continuous intravenous dextrose infusion with liberal oral intake, and continued to have recurrent hypoglycemic episodes 96 h into her hospital stay. She was discharged on hospital day 5 after psychiatric clearance without any permanent complications. CONCLUSIONS:A single massive overdose of insulin glargine can present with prolonged hypoglycemia. Emergency physicians should have a low threshold for initiating continuous dextrose infusions and admitting these patients for frequent blood glucose and serum electrolyte monitoring, preferably in an intensive care setting.
Octreotide for the treatment of hypoglycemia after insulin glargine overdose.
Groth Christine M,Banzon Eleanor R
The Journal of emergency medicine
BACKGROUND:Intentional insulin glargine overdose is rarely reported in the literature, but usually results in prolonged hypoglycemia requiring intensive care unit admission. OBJECTIVE:We report a case of using octreotide to treat prolonged hypoglycemia after a large insulin glargine overdose. CASE REPORT:A 56-year-old man with type 2 diabetes mellitus presented to the Emergency Department after a multidrug overdose including up to 3,300 units insulin glargine. He required admission to the intensive care unit for mechanical ventilation and blood-glucose monitoring every 30 to 60 min. He received a continuous dextrose infusion for >100 h for persistent hypoglycemia. Octreotide, a somatostatin analogue, was given on day 4 of admission in an attempt to inhibit any insulin secretion from the pancreas that might be occurring in response to the dextrose infusion and to minimize the amount of fluid being given. After three doses, improvements in the patient's blood glucoses were seen, however, this could have coincided with complete absorption of the insulin. CONCLUSIONS:Prolonged hypoglycemia often occurs after large overdoses of insulin glargine due to a depot effect at the site of injection. Octreotide is a potential adjunctive treatment to dextrose in patients with a functioning pancreas.
Intravenous glucagon in a deliberate insulin overdose in an adolescent with type 1 diabetes mellitus.
White Mary,Zacharin Margaret R,Werther George A,Cameron Fergus J
Massive insulin overdose may be associated with unpredictable and prolonged hypoglycemia. Concerns surrounding the potential provocation of insulin release from beta cells have previously prevented the use of intravenous glucagon as an adjunct to infusion of dextrose in this situation. We describe the case of a 15-yr-old boy with type 1 diabetes mellitus (T1DM) who presented with profound hypoglycemia following an overdose of an unknown quantity of premixed insulin. Owing to an increasing dextrose requirement and a dependence on hourly intramuscular glucagon injections, a continuous intravenous infusion of glucagon was commenced which successfully avoided the requirement for central venous access or concentrated dextrose infusion. Nausea was managed with anti-emetics. Intramuscular and subcutaneous glucagon is effective in the management of refractory and severe hypoglycemia in youth with both T1DM and hyperinsulinism. Concerns regarding the precipitation of rebound hypoglycemia with the use of intravenous glucagon do not relate to those with T1DM. This treatment option may be a useful adjunct in the management of insulin overdose in youth with T1DM and may avoid the requirement for invasive central venous access placement.
Interpreting insulin immunoassays during investigation of apparent spontaneous hypoglycaemia and insulin overdose.
Chemmanam Julie,Isaacs Michelle,Jones Graham R,Greenfield Jerry R,Burt Morton G
Internal medicine journal
We report two cases of hypoglycaemia; one with apparently spontaneous hypoglycaemia and one with presumed insulin overdose. In both cases insulin concentration was normal when measured with the Roche immunoassay, but elevated when remeasured with the Advia Centaur immunoassay and a diagnosis of hypoglycaemia secondary to insulin analogue administration was made. These cases highlight that physicians need to understand the binding characteristics of the insulin immunoassay they use.
Insulin degludec overdose may lead to long-lasting hypoglycaemia through its markedly prolonged half-life.
Uchida J,Oikawa Y,Katsuki T,Takeda H,Shimada A,Kawai T
Diabetic medicine : a journal of the British Diabetic Association
BACKGROUND:Overdose of insulin often causes long-lasting severe hypoglycaemia. Insulin degludec has the longest duration of action among the available insulin products; thus, an overdose of insulin degludec can lead to long-lasting hypoglycaemia. In the present paper, we report the case of a woman with long-lasting hypoglycaemia attributable to insulin degludec overdose and markedly prolonged insulin degludec half-life. CASE REPORT:A 64-year-old woman with Type 2 diabetes receiving insulin therapy was taken to an emergency department because of disturbed consciousness 21 h after self-injection of 300 units of insulin degludec (4.34 units/kg). Her plasma glucose level was 2.3 mmol/l. She received repeated intravenous boluses of dextrose for 43 h with continuous intravenous dextrose infusion, but no improvement in long-lasting hypoglycaemia or consciousness was observed. Considering the possibility of adrenal insufficiency, intravenous dexamethasone was administered, and her plasma glucose levels subsequently remained above 5.5 mmol/l without intravenous dextrose boluses. She gradually regained consciousness. A total of 34 h after the overdose, her plasma immunoreactive insulin levels were markedly increased and then gradually declined over ~400 h. The insulin degludec half-life was 40.76 h. CONCLUSION:Although the reported half-life of insulin degludec in the body is ~25 h when administered in standard doses (0.4-0.8 units/kg), no study has investigated its half-life after overdose. In the present case, the half-life of insulin degludec was ~1.6 times longer than that observed with standard doses, probably leading to long-lasting hypoglycaemia. Physicians should be aware of the possibility of unexpected long-lasting severe hypoglycaemia resulting from insulin degludec overdose.
Octreotide for the treatment of intentional insulin aspart overdose in a non-diabetic patient.
Dewaal Catherine M,McGillis Eric,Mink Matt,Lucyk Scott
Intentional insulin overdose may lead to severe and refractory hypoglycemia. Exogenous dextrose administration is the mainstay of therapy for these patients and is effective in most cases. However, in patients with a functional pancreas, exogenous dextrose administration may precipitate endogenous insulin release leading to rebound hypoglycemia. We describe a case report of a 41-year-old woman who injected 300 units of insulin aspart with suicidal intent. Her initial blood glucose was 2.3 mmol/L (41 mg/dL). Over the next 12 hours, she experienced recurrent hypoglycemic episodes despite 10% dextrose infusions and 14 ampoules of 50% dextrose. Our patient experienced complications, including peripheral edema, related to the large volumes of intravenous dextrose required to attempt to maintain euglycemia. Octreotide, a somatostatin analogue, may help prevent dextrose-induced hypoglycemia and improve the management in select insulin overdose patients; large infusion volumes resulted in significant peripheral edema. Treatment with octreotide was initiated 12.5 hours post-injection and was followed by a stabilization of blood glucose concentration in this non-diabetic patient.