SAT-563 - Octreotide Treatment for Persistent Sulfonylurea-Induced Hypoglycemia in Acute Renal Insufficiency

Introduction: Octreotide in conjunction with dextrose is the standard first-line therapy for sulfonylurea-induced hypoglycemia. This case underscores the efficacy of octreotide in a patient with acute renal insufficiency, who despite not having taken his prescribed sulfonylurea for one week, presented with persistent hypoglycemia.

Case Description: An 81-year-old male with a history of squamous cell carcinoma of the buccal mucosa presented to the emergency department with bleeding from his feeding tube site, urinary retention, and persistent hypoglycemia over the past 4 days. He had type 2 diabetes, managed with glimepiride 1mg twice daily via feeding tube. He last took glimepiride 1 week prior, as his glucose levels had fallen below the holding threshold. In the several days prior to admission, he experienced persistent, asymptomatic episodes of hypoglycemia, which he treated with juice.

Upon admission, he was diagnosed with acute renal insufficiency, with labs showing a creatinine of 3.7 mg/dL and an eGFR of 15 mL/min/1.73m2. His initial point-of-care glucose was 31 mg/dL. The emergency team administered 50 grams of 50% dextrose solution (D50W), raising his glucose to 104 mg/dL within minutes; however, four hours later his glucose dropped again to 34 mg/dL. This prompted endocrinology consultation, another dose of D50W, and initiation of continuous dextrose-containing fluids. Despite being on continuous tube feeding and dextrose, he continued to have labile glucose levels and frequent hypoglycemic episodes overnight.

Because of the patient’s acute renal insufficiency and suspected impaired clearance of glimepiride, octreotide was administered. A single dose of 50 mcg of octreotide was given subcutaneously when his blood glucose again decreased to 63 mg/dL. Subsequently, his glucose increased to 184 mg/dL, the highest value since admission. Dextrose fluids were discontinued and his glucose remained stable in the 100-140 mg/dL range for the remainder of his hospitalization. Glimepiride was stopped on discharge.

Conclusion: This case demonstrates how impaired renal clearance can prolong sulfonylurea effects, resulting in persistent hypoglycemia days after the last dose. Octreotide acts by inhibiting insulin secretion at the pancreatic beta cell level, rapidly stabilizing blood glucose and significantly reducing the risk of recurrent hypoglycemic episodes compared to dextrose alone. Octreotide is safe and effective in both adult and pediatric populations, including in those with comorbidities such as congestive heart failure or renal failure, where prolonged IV dextrose infusion may pose additional risks such as fluid overload. This case underscores the immediate efficacy of octreotide in complex clinical situations where dextrose alone is insufficient to correct blood glucose levels.

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