CASE REPORT

A 46-year-old male developed sudden onset confusion and agitation at home and was unable to answer questions from his partner. Emergency medical services (EMS) were called, and on arrival, the patient’s Glasgow Coma Scale was reported as 8/15; his vital signs were: blood pressure of 124/76, heart rate of 104 beats per minute, temperature of 36.0°C, and respiratory rate of 18 breaths/minute. Blood glucose testing revealed a level of 1.3 mmol/L (normal range 3.3–11.0 mmol/L). Immediate administration of 50 mmol of intravenous (IV) dextrose quickly improved the patient’s level of consciousness and blood glucose levels to 7 mmol/L.

In the emergency department (ED), the patient admitted to attempting suicide by injecting 36 mg of liraglutide subcutaneously (20 times the maximum recommended dose) that had been prescribed to his partner. He took the medication approximately five hours before becoming symptomatic. The patient thought he might have taken some of his partner’s other medications; however, all her medications were in their respective blister packs. The patient’s vital signs and mental status were stable, and he was initiated on an IV dextrose infusion (Figure 1). Approximately five hours after the dextrose infusion was started, the patient had a second hypoglycemic episode (2.8 mmol/L) that corrected with a 50 mL bolus of 50% IV dextrose. He initially required an infusion of 50% dextrose titrated up to 175 mL/h to maintain a blood glucose level of 7.0 mmol/L. The patient’s serum levels of acetaminophen, salicylate, and ethanol were all negative. A comprehensive drug screen was not sent. Initial liver enzyme testing was normal: alanine aminotransferase, 36 U/L; alkaline phosphatase, 63 U/L; bilirubin total, 14 µmol/L; lipase 38 U/L; and lactate dehydrogenase 66 U/L. The patient had an anion gap of 12, osmolar gap of 1, and venous pH of 7.42. An electrocardiogram showed a normal sinus rhythm with a QTc of 457 ms, and a chest x-ray was normal.

Figure 1 Glucose infusions to maintain serum blood glucose.

The patient had a history of borderline personality disorder, prior suicide attempts, and chronic pain. He had no history of diabetes (hemoglobin A1c of 5.4%, one year prior). His home medications included gabapentin, acetaminophen, quetiapine, and zopiclone. His partner reported that the patient was out of his medications for several days and that there were no other medications available to him besides the liraglutide and the accounted for blister-packed medications. There were no other evident causes of hypoglycemia besides the liraglutide overdose, including liver disease, access to exogenous insulin, or alcohol toxicity.

The regional poison centre was consulted and recommended the administration of octreotide, in addition to IV dextrose and supportive care, hypothesizing that it may decrease the secretion of insulin as it does in sulfonylurea toxicity. Fifty micrograms of octreotide was administrated subcutaneously two hours after presentation and continued every six hours for three additional doses. It is unclear if there was any impact on the patient’s blood glucose level. No glucagon was given.

The patient was admitted to the intensive care unit (ICU) where he was treated with an infusion of 50% dextrose that was weaned over 48 hours. There was no recurrent hypoglycemia for the 24 hours after discontinuation. At admission, the patient had persistent nausea, eight episodes of vomiting over 24 hours, and mild abdominal pain. He was treated with metoclopramide, 10 mg IV every 8 hours, and acetaminophen, 500 mg every 6 hours. The symptoms resolved after 24 hours. His liver functioning tests including lipase remained normal. The patient also required correction of hypophosphatemia and hypokalemia during the first 48 hours of the hospital admission. He did not experience any other adverse symptoms, made a full recovery, and was discharged home four days after admission.