PSUN253 Cocaine Use Resulting in Inadvertent Sulfonylurea Overdose

INTRODUCTION: Most street cocaine is cut with other substances to increase drug volume. Often, cutting agents are used that change or intensify the effects of the drug. We present a case in which sulfonylurea-laced cocaine resulted in life-threatening hypoglycemia. CLINICAL CASE: A 61-year-old male with a history of heart failure with reduced ejection fraction, moderate aortic stenosis, and substance abuse was found unconscious with a fingerstick of 25 mg/dL. He had no personal history of diabetes. No one in his household had diabetes, and he denied any use of insulin or oral anti-diabetic medications. In the emergency department, he had recurrent hypoglycemia despite D10 boluses, glucagon, oral glucose tablets, and a full meal. He required initiation of a continuous intravenous D10 drip, which was titrated to 250 mL/hr to maintain normoglycemia. The endocrinology service was consulted for further evaluation and treatment. The patient recalled smoking a new supply of cocaine prior to his current admission. He had been admitted to two other hospitals within the month prior with similar episodes of severe hypoglycemia. Biochemical evaluation during a prior hospitalization suggested hyperinsulinemic hypoglycemia and a CT abdomen did not visualize an insulinoma. However, diagnostic evaluation was not completed at that time as the patient left against medical advice.Tests during this hospitalization included a low serum glucose 42 mg/dL, high insulin 107 uIU/mL (normal <3), high proinsulin 42.8 pmol/L (normal <5 pmol/L), high c peptide 13 ng/mL (normal <0.6) and low beta-hydroxybutyrate 1.2 mg/dL (normal >2.7mg/dL), consistent with hyperinsulinemic hypoglycemia. Other results included negative insulin antibody, normal TSH, and appropriately elevated cortisol levels. Given desire to rapidly wean D10 drip to avoid volume overload, octreotide therapy was initiated. He received octreotide 50mcg subcutaneously three times over a span of 24 hours, and the D10 drip was discontinued. His sulfonylurea screen subsequently resulted positive for glipizide. Considering the timing of cocaine use preceding the onset of hypoglycemia, it was postulated that the hyperinsulinemic hypoglycemic event was due to use of cocaine that was intermixed with sulfonylurea. CONCLUSION: In cases of hypoglycemia with a known history of illicit substance abuse, clinicians should consider the presence of contributing cutting agents, such as sulfonylureas. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.