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Case Report | DOI: https://doi.org/10.31579/2640-1045/109
1 Clinical pharmacist, Indonesian hospital- Gaza Strip- Palestine.
2 PhD. Medical doctor, Indonesian hospital-Gaza strip- Palestine.
*Corresponding Author: Lu Cixin, Clinical pharmacist, Indonesian hospital- Gaza Strip- Palestine.
Citation: Mao Tang, Lu Cixin. (2022). Refractory Hypoglycemia due to Humulin 70/30 Insulin Overdose: A Case Report. Endocrinology and Disorders. 6(2): DOI:10.31579/2640-1045/109
Copyright: © 2022 Mao Tang, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 30 October 2021 | Accepted: 20 December 2021 | Published: 07 January 2022
Keywords: hypoglycemia; diabetes; humulin insulin; dextrose
Humulin 70/30 insulin is an intermediate acting medication used for treatment diabetes mellitus. According to systematic review and there have been forty four case reports of overdoses with different types of insulin.
We present a unique case of insulin Humulin 70/30 overdose due to suicidal attempt that presented with persistent hypoglycemia and required prolonged hospital treatment.
A47 years old female patient presented to the emergency department due to decreased level of consciousness after self -administration of 2000 international unit Humulin insulin 70/30 suicidal attempt. In the emergency department patient treated with 250 ml D10% then shifted to the medical department. The patient continue treatment with dextrose 10% 200 ml/hour as continuous infusion, unfractionated heparin 7500 international unit/12 hour, hydrocortisone 100mg /6 hours, octreotide 100 microgram /8 and glucagon 1 mg . On the fourth day all medication and D10% stopped and the patient still under observation then discharged on will general condition without hypoglycemia attacks.
A single high overdose of Humulin insulin can present with prolonged persistent hypoglycemia that is refractory to D10% alone. All physicians should know the guidelines to treat severe form of hypoglycemia and when to admit into medical department or intensive care unit with follow up for blood glucose and serum electrolyte monitoring.
Humulin insulin 70/30(insulin isophane human 70 unit/insulin regular human 30 unit)/ml is intermediate acting is used to treat diabetes mellitus. It is the mostly prescribed type of insulin in Gaza Strip. The most important adverse effect of insulin in emergency department is hypoglycemia. Herein, we report a case of Humulin insulin overdose resulting five days (120 h) of hypoglycemia in a diabetic patient after self-administration of 2000 IU Humulin suicidal attempt. For our knowledge, this is the highest reported Humulin insulin dose ever reported and the first time ever faced in Gaza Strip hospitals.
A47 years old female patient presented to the emergency department due to decreased level of consciousness after self -administration of 2000 international unit of Humulin insulin (70/30) unit/ml suicidal attempt. Assessment in the emergency department reveal random blood glucose level 20 mg/dl, temperature 36, oxygen saturation 98%, blood pressure 167/74 mmHg, heart rate 107 beat per minute. Patient laboratory data on admission were as follow: AST 52 IU, Na 142 mmole, K3.5mmole, Ca ionized 1.1 mmole, creatinine 0.8, complete blood count reveal WBC 18.1, HGB 12.1 g/dl, PLT 228. The patient received 250 ml Dextrose 10% as emergency treatment for sever hypoglycemia, then admitted to the medical department. Patient medical history consisted of insulin-dependent diabetes mellitus since 20 years treated with NPH (40 unit Am, 40 unit mid-day and 40 unit afternoon) and hypertension since 20 years on Enalapril 10 mg per day. In the medical department patient treated with dextrose 100 ml/hour as continuous infusion due to none availability of D50% or D20% with regular blood glucose level measurment every two hours. On the second day patient blood sugar level still fluctuated around 60 mg/dl (see fig 1 below), so the rate of D10% increased to 200 ml/hour, unfractionated heparin 7500 international unit/12 hour was added. On the third day hydrocortisone 100 mg/6 hours, octreotide 100 microgram /8 hours added to counter the release of endogenous insulin due to dextrose administration and glucagon 1 mg also added to over persistent hypoglycemia.
On the fourth day patient improved dramatically clinically and her blood glucose level stabilized above 110 mg /dl, so octreotide withdrawn, hydrocortisone dose decreased to 100 mg /8 hours, D10
Insulin overdose is a challenging clinical problem in the emergency department [1]. There are lot of cases reported hypoglycemia due to insulin but reports of massive overdoses in the literature remain rare. During our search we found a number of case reports of large insulin overdoses the largest of which was 10, 000 units of Humulin R. Other overdoses were 800 units of lispro, 3,800 units of glargine, 2,500 units of NPH insulin, 750 units regular insulin and 750 units NPH insulin and 1,500 units of overdose of insulin glargine was also reported. [2-8]. Of 1,523 published articles, 45 cases of insulin overdoses were included with a total median insulin dose of 900 international units (IU) (range 2,600-, 800 IU).
Insulin overdose is a medical emergency, most cases can be treated in the medical ward but some cases requires intensive care admission and frequent monitoring of blood glucose and electrolytes. Treatment mainly continuous dextrose infusion (D10%or25% or 50%). Intravenous infusion of D10
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