Death by Insulin!

Robert J. Tanenberg, MD, FACP

Dr Elliot Joslin once noted that: “Ketoacidosis may kill a patient, but frequent hypoglycemic reactions will ruin him” *

This is a case of a young patient with Type 1 Diabetes who died from Hypoglycemia recorded by a Continuous Glucose Monitoring System

* Founder of world famous Joslin Diabetes Clinic in Boston.

Hypoglycemia: Definition

Most frequent acute complication among person treated with insulin or oral hypoglycemic agents

Blood glucose < 70 mg/dl indicative of impending hypoglycemia

Biochemical hypoglycemia blood glucose < 50 mg/dl

Mild Hypoglycemia

Adrenergic or cholinergic symptoms

• pallor
• diaphoresis
• tachycardia and palpitations
• hunger
• paresthesias,
• shakiness
• Totally alert
• Able to self treat

Moderate Hypoglycemia

• Neuroglycopenia
• inability to concentrate
• confusion
• slurred speech
• irrational or uncontrolled behavior
• slowed reaction time
• blurred vision,
• somnolence, or extreme fatigue

Still able to self treat or ask for assistance

Severe Hypoglycemia

An episode of neuroglycopenia so severe that another person is required for treatment

Symptoms include:

• disoriented behavior
• loss of consciousness
• inability to arouse from sleep
• seizures

Diabetes Drugs That Can Cause Hypoglycemia

•Insulins

Sulfonylureas (SU)

Worst offenders:

Chlorpropamide > Glyburide > Glimepiride >Glipizide

Combos with SU:

•Glucovance, Avandaryl, Metaglip, Duetact

•Glinides

Nateglinide (Starlix) and Repaglinide (Prandin)

Hypoglycemia is more common and may be more serious (even fatal ) in patients with a coexisting decrease in GFR, liver disease, starvation, alcoholism or drug abuse and in the elderly.