Hypoglycemia Secondary to Intentional Insulin Poisoning Managed With Intravenous Hydrocortisone

Insulin poisoning, defined as the administration of any dose exceeding therapeutic levels, is a medical emergency that can lead to profound hypoglycemia, resulting in acute and long-term neurological sequalae and death. Current Australian therapeutic guidelines recommend oral or IV glucose as the sole treatment modality for hypoglycemia resulting from insulin poisoning. However, the altered pharmacokinetics of insulin glargine at doses exceeding 0.9 IU/kg can result in prolonged hypoglycemia, often necessitating several days of IV glucose to maintain euglycemia. Although IV glucose is generally considered a benign intervention, its prolonged use can be associated with several adverse effects, including thrombophlebitis, extravasation necrosis, fluid overload, hyponatremia, and glycogenic hepatopathy. To reduce these complications, adjunct therapies such as glucocorticoids, octreotide, glucagon, and surgical excision of subcutaneous insulin deposits have been described in the literature. We report a case of refractory hypoglycemia secondary to insulin poisoning managed with IV hydrocortisone as an adjunctive therapy to IV glucose. To the authors knowledge, this is the first case report describing the use of IV hydrocortisone as a single adjunct in this setting.