Severe neuroglycopaenia secondary to severe hypoglycaemia from serendipitous overdose of gliclazide without adrenergic or autonomic response

Abstract

low affinity of insulin detemir for the IGF-1 receptor (approximately one-tenth of that of human insulin) [1] could prove beneficial in the treatment of pregnant women, particularly as regards the effect on birthweight and maternal complications. Thus, to determine the drug's safety in pregnancy, we focused first on congenital malformations, given that all the women used insulin detemir during the period of embryogenesis [4]: our findings seem to exclude any effect on embryo-foetal development.Another issue is the potential effect on foetal growth. One concern is that the affinity of insulin analogues for the IGF-1 receptor could potentially cause foetal macrosomia. In our series, however, the use of insulin detemir throughout pregnancy was not associated with a higher birthweight or any changes in neonatal outcome. In addition, the prevalence of macrosomia and ⁄ or large for gestational age (LGA) was within the range for Type 1 diabetic women using other forms of insulin [5]. This study was performed in a small cohort of women, but it is the first report on the use of insulin detemir in human pregnancy. Judging from our results, insulin detemir seems to help improve glycaemic control and does not appear to have any adverse effects on maternal or foetal outcome in Type 1 diabetic women. Studies on larger series of patients and randomized controlled trials are warranted to further assess the safety and effectiveness of insulin detemir in pregnancy. References1 Home P, Bartley P, Russell-Jones D, Hanaire-Broutin E, Heeg JE, Abrams P et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with type 1 diabetes: a randomized clinical trial.We agree with the observations made by Dalan et al.[1] on the inappropriate autonomic and adrenergic responses to severe hypoglycaemia in sulphonyurea overdose. We describe our experience with a 16-year-old boy who was admitted in a comatose state as a result of gliclazide-induced hypoglycaemia.He was an orphan living with a guardian (maternal uncle). Apart from mild learning difficulties, he had no known medical illnesses and was not on any regular medications. On the day of admission, he was noted by his guardian to be restless in his sleep and unable to be aroused. No abnormal behaviour was noted the day before, nor did he complain of hunger, sweating, palpitations, anxiety or other adrenergic symptoms before he went to bed at his usual time. He was very restless when he was first seen in the emergency department of a district general hospital. Vital signs were within the normal range (blood pressure 120 ⁄ 80 mmHg, pulse 82 b ⁄ min, regular) except for very low capillary blood glucose (undetectable on the glucose meter). In view of the restlessness and persistent hypoglycaemia, multiple boluses of i.v. dextrose 50% and i.v. benzodiazepines (midazolam) were given. He was then referred to our hospital for further management. Upon arrival, his Glasgow Coma Scale was 5 ⁄ 15 with oxygen saturation of 75-80% on room air, blood pressure 110 ⁄ 84 mmHg,...