SUN-179 Prolonged Hypoglycemia from Insulin Degludec

Prolonged Hypoglycemia from Insulin Degludec Background:  Patients with type 2 diabetes treated with insulin degludec compared with insulin glargine had a reduced risk of overall symptomatic hypoglycemia (1). This is primarily due to former’s long half-life (25 hours) and lack of trough levels. Moreover, insulin degludec’s pharmacokinetics is not affected by renal impairment and no dose adjustment is needed in impaired renal function (2). Case:  75 y/o female with history of type 2 diabetes, chronic kidney disease stage III, pancreatitis and pancreatic cyst status post drainage presented with frequent episodes of symptomatic hypoglycemia.Patient was switched from insulin glargine to degludec 6 units(U) daily and continued on aspart 6 units(U) TID and metformin 500mg BID three months prior to presentation. When seen in clinic two months later, she had frequent episodes of blood glucoses (BG) in 40s-50s mg/dl. Degludec was reduced to 5U and aspart to 1U for 1 carb serving, maximum 3U per meal. Two weeks later she was seen in primary care clinic with BG of 36 mg/dl when all insulin was stopped. One week later she was seen in the emergency room with BG of 37mg/dl. She was treated and discharged home. Three days later she continued to have symptomatic hypoglycemic episodes 1-2 times a day, (BG 40s mg/dl), especially in fasting state and was then hospitalized.On admission, her BG was 66mg/dl. She was started on dextrose drip. Labs showed glomerular filtration rate (GFR) of 30.1 ml/min/1.73m(2) which had reduced from 54.1 ml/min/1.73m(2) three months ago when degludec was started. Her fasting insulin, pro-insulin levels, C-peptide, beta-hydroxy butyrate, IGF1 were in normal range, along with simultaneous plasma glucose of 144 mg/dl. She had normal liver function, TSH and a normal response to ACTH stimulation test. She received IV hydration with improvement in GFR to 40.3 ml/min/1.73m(2). She was encouraged to eat more as patient had poor appetite since her pancreatic cyst drainage four months ago. She was observed for two days in the hospital and her BG remained in 154 to 213 mg/dl with one value of 306 mg/dl. She was discharged on metformin 500 mg daily and aspart 2U if BG > 250mg/dl. Subsequent follow up one and four weeks later showed no episodes of hypoglycemia. Conclusion: The case above illustrates prolonged action of degludec causing hypoglycemia 10 days after stopping prescription dose (0.1U/kg) of degludec, which has not been previously reported before.Reduced oral intake potentiated hypoglycemic episodes. Practitioners should be aware of potential prolonged hypoglycemia from degludec. (1) The SWITCH 2 Randomized Clinical Trial. JAMA. 2017;318(1):45-56 (2) Clin Pharmacokinet. 2014 Feb;53(2):175-83