A Bizarre Case of Recurrent Hypoglycemia

Introduction: Severe hypoglycemia is extremely rare in non-diabetic subjects and requires thorough evaluation due to its life threatening consequences. Any injuries resulting from medication use, including physical harm, mental harm, or loss of function is defined as adverse drug events (ADEs). Medication errors can occur due to the inappropriate use of medicine in any prescription stage. We hereby present an intriguing case of recurrent hypoglycemia in relation to it. Case presentation: A 65 year-old white male with surgically induced panhypopituitarism on replacement hydrocortisone, levothyroxine and testosterone was transferred to our hospital with recurrent serious hypoglycemic episodes. He was in his usual state of health until about 2 weeks prior to presentation when he became increasingly fatigued. He was found to have severe hypoglycemia with a blood sugar of 20 mg/dl. He was treated for hypoglycemia and was discharged home 2 days later with an increased dose of hydrocortisone and the provisional diagnosis of adrenal crisis. At home, his symptoms of hypoglycemia recurred. He was then referred to our facility where the Endocrinology service was consulted. At admission, his blood sugar was 69 mg/dl, but it rapidly dropped down to 39 mg/dl with confirmatory serum glucose level of 24 mg/dl. He was started on Dextrose 10%. On further inquiry his daughter told us that she had discovered two different medications in one prescription bottle which had been refilled about 2 weeks prior to this hospitalization, coinciding with the onset of symptoms. The bottle in question was supposed to be for hydrocortisone 10 mg tablets, but it contained 2 different tablets with inscription GXL10 and P10. An online search identified tablets as Glucotrol-XL 10 mg and hydrocortisone 10 mg. Urine drug screen (UDS) for sulfonylureas and glinide was positive for Glipizide (203 ng/ml, normal level 0). His blood sugar stabilized with Dextrose and he was safely discharged home. So it was concluded that recurrent hypoglycemia was secondary to inadvertent administration of hypoglycemic agents, Glucotrol-XL 10 mg, likely aggravated by missing doses of hydrocortisone. Discussion: The first report of medication errors was published in 1940. ADEs comprise the largest single category of adverse events experienced by hospitalized patients,accounting for about 19 percent of all injuries. ADEs are associated with increased morbidity and mortality, prolonged hospitalizations, and higher costs of care. Four medications or medication classes were implicated in 67% of hospitalizations: warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents. ADEs in the outpatient setting are an important cause of emergency department visits and hospital admissions. This case emphasized the importance of taking a thorough history and focusing on patient safety and quality care in healthcare.