From the Guidelines
Intentional insulin poisoning should be suspected in cases of unexplained hypoglycemia, particularly when neurological symptoms are present, and the patient's history and context do not match their usual insulin requirements. This condition can be a method used in homicides, suicides, and factitious disorder (Munchausen syndrome) 1. Healthcare providers should be vigilant in cases involving healthcare workers, caretakers of vulnerable individuals, or those with access to insulin. The diagnosis of intentional insulin poisoning is challenging due to the natural presence and quick degradation of insulin in the body, but C-peptide levels can help differentiate between endogenous and exogenous insulin.
Key Considerations
- Insulin is one of the most common medications causing adverse events in hospitalized individuals, often due to errors in dosing, administration, or management 1.
- Recent studies have shown that bundled preventive therapies, including proactive surveillance of glycemic outliers and an interdisciplinary data-driven approach to glycemic management, can reduce hypoglycemic episodes in the hospital by 56-80% 1.
- The use of continuous glucose monitoring (CGM) as an early warning system to alert of impending hypoglycemia offers an opportunity to mitigate it before it happens 1.
- Treatment of intentional insulin poisoning involves immediate administration of dextrose to restore blood glucose levels, with close monitoring as the duration of hypoglycemia depends on the insulin type used.
Management and Prevention
- Immediate administration of dextrose (typically D50W followed by D10W infusion) is crucial to restore blood glucose levels.
- Close monitoring is necessary as the duration of hypoglycemia depends on the insulin type used (rapid-acting insulins like lispro cause shorter hypoglycemia than long-acting formulations like glargine).
- Octreotide may be used in cases of sulfonylurea poisoning but is not effective for insulin overdose.
- The investigation should include thorough toxicology screening and careful documentation of all findings for potential legal proceedings.
From the FDA Drug Label
OVERDOSAGE Excess insulin may cause hypoglycemia and hypokalemia, particularly after intravenous administration. The FDA drug label does not answer the question.
From the Research
Intentional Insulin Poisoning Research
- Intentional insulin poisoning is a medical emergency that can lead to profound hypoglycemia, resulting in acute and long-term neurological sequelae and death 2.
- The management of insulin poisoning differs from hypoglycemia induced by therapeutic doses of insulin, and guidelines on treatment are not well established 3.
- Treatment with glucose infusion, sometimes supplemented with glucagon, is almost always effective in restoring euglycemia, but optimum treatments to maintain euglycemia and restore cerebral function remain uncertain 3.
Prognostic Factors and Toxicokinetic/Toxicodynamic Profiles
- Delay to therapy in excess of 6 hours and ventilation for longer than 48 hours are identified as independent prognostic factors for intentional insulin poisoning 4.
- The observed plasma insulin EC50 is 46 mIU/l, which can be used to guide treatment and predict outcomes 4.
- Toxicokinetic/toxicodynamic relationships between glucose infusion rates and insulin concentrations can be modeled using the maximum measured glucose infusion rate (Emax) model 4.
Treatment Options and Outcomes
- IV hydrocortisone can be used as an adjunctive therapy to IV glucose in the management of refractory hypoglycemia secondary to insulin poisoning 2.
- Octreotide may reduce glucose levels in both the fasting and postprandial states by suppressing extrapancreatic glucagon 5.
- The use of glucagon, octreotide, and surgical excision of subcutaneous insulin deposits have been described in the literature as potential treatments for insulin poisoning 3.
- The survival rate for insulin poisoning has improved over time, with a reported survival rate of 96% between 2000 and 2022 3.