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Persistent Hyperinsulinemia Following High-Dose Insulin Therapy: A Case Report.

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  • 1Minnesota Poison Control System, 701 Park Ave RL.240, Minneapolis, MN, 55415, USA. corco049@gmail.com.

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Summary

High-dose insulin (HDI) therapy for beta-blocker and calcium channel blocker overdoses may allow for simple discontinuation, as supraphysiologic insulin levels persist post-therapy. This finding aids in managing these critical poisoning cases.

Keywords:
Beta-blockerCalcium channel-blockerHigh dose insulinOverdosePoisoning

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Area of Science:

  • Toxicology
  • Pharmacology
  • Emergency Medicine

Background:

  • Overdoses of beta-adrenergic antagonists and calcium channel antagonists are rare but severe clinical events.
  • Potential treatments include fluids, calcium salts, vasopressors, intravenous lipid emulsion, methylene blue, and high-dose insulin (HDI).
  • The pharmacokinetics of insulin during HDI therapy for these overdoses are not well understood.

Observation:

  • A case report details a 51-year-old male with a life-threatening overdose of amlodipine and metoprolol tartrate.
  • The patient received HDI therapy augmented with epinephrine for severe bradycardia and hypotension.
  • Following discontinuation, serum insulin levels remained supraphysiologic for at least 24 hours and above reference range for days.

Findings:

  • Supraphysiologic insulin levels persist for a significant duration after HDI therapy cessation in overdose patients.
  • This prolonged presence of insulin may permit straightforward discontinuation of HDI without complex titration.
  • Dextrose replacement is necessary, but the duration of need is unpredictable, potentially not requiring prolonged infusions.

Implications:

  • Understanding insulin kinetics post-HDI therapy can simplify treatment protocols for severe poisonings.
  • This case suggests that HDI discontinuation can be managed without tapering, potentially reducing ICU resource utilization.
  • Further research into insulin pharmacokinetics in overdose scenarios is warranted to refine treatment guidelines.