A 27-year-old female with a history of bipolar 1 disorder, borderline personality disorder, posttraumatic stress disorder (PTSD), previous history of multiple suicide attempts, T2DM, and obesity (weight 160 kg; body mass index 56 kg/m2) status-postsleeve gastrectomy in 2016 presented to the emergency department (ED) following a suicide attempt. She was brought to the ED by self-notifying emergency services after having shortness of breath and dizziness following self-injection of 900 units of insulin glargine U-100 (Lantus ) subcutaneously into her abdomen three hours prior. This represented her third intentional insulin overdose in the preceding six months. She was previously insulin-requiring, on Lantus, but was weaned off insulin four years ago after sleeve gastrectomy and subsequent 68 kg weight loss over the preceding five years. The patient's most recent hemoglobin A1c (HbA1c) ten months prior to presentation, while off insulin or any other hypoglycemic agents, was 4.7%. Home medications at this time included duloxetine 120 mg daily, bupropion 300 mg daily, lithium 900 mg daily, prazosin 5 mg at bedtime, trazodone 150 mg at bedtime, and mirtazapine 30 mg at bedtime.
The patient reported suicidal ideation and worsened depression for three months prior to presentation and decided to inject three full insulin glargine U-100 pens (300 units each), which she had at home from her prior insulin prescription. The initial fingerstick blood glucose taken by paramedics prior to arrival to the ED was 131 mg/dL. At that time, she was closely monitored, but not medically treated, and was sent to the ED. Her fingerstick blood glucose level upon presentation to the ED was 113 mg/dL, at which time she was somnolent but arousable and answering questions appropriately. Her physical examination upon arrival was unremarkable and did not reveal any areas of fluctuance at the reported injection sites.
 Figure 1 depicts the patient's course of therapy from the time of ED presentation. An intravenous (IV) 10% dextrose (D10) infusion was started at 300 mL/hour 30 minutes after ED arrival to prevent hypoglycemia. A regular diet was started and carbohydrate intake was encouraged. Fingerstick glucose levels were monitored every 15 minutes for the first seven hours and every 30 minutes thereafter. The patient's blood glucose readings first approached the hypoglycemic range of <70 mg/dL approximately three hours after presentation (fingerstick blood glucose = 74 mg/dL). She received two 50-gram ampules of dextrose 50% (D50) IV, along with three 1 mg doses of intramuscular (IM) glucagon, over the next four hours in addition to the D10 IV infusion. The patient was then transferred to the medical intensive care unit (MICU) for close observation.
Due to persistent hypoglycemia and inability to wean the D10 IV infusion, a standing order for glucagon 1 mg IM for blood glucose <70 mg/dL was added. During the first 48 hours of her admission, she required eleven 1 mg IM glucagon doses in addition to the D10 IV infusion but continued to experience hypoglycemia with the lowest recorded blood glucose reading of 64 mg/dl. She was transitioned from a standard diet to a bariatric diet due to suspected reactive hypoglycemia associated with her postbariatric surgery status, which consisted of 56 grams of carbohydrate and 18 grams of protein per day. An IV glucagon infusion was started at 1 mg/hr on hospital day two (approximately 44 hours after presentation) in a continued effort to minimize IV fluid volume. In addition, a trial dose of hydrocortisone 100 mg IV bolus was given at the time the IV glucagon infusion was started. The IV glucagon infusion was titrated to 2 mg/hr as the D10 IV infusion was weaned off, which was done on hospital day three (approximately 73 hours after presentation). However, the patient's glucose levels began trending towards the hypoglycemic range, requiring further titration of the IV glucagon infusion to 4 mg/hr. Hydrocortisone 100 mg IV every 8 hours was then started to reduce the IV and IM glucagon requirements. The IV glucagon infusion was weaned off on hospital day four after three additional doses of hydrocortisone on days 3 and 4. The patient became hyperglycemic following the last dose of hydrocortisone (blood glucose = 309 mg/dL), which prompted discontinuation of the stress-dose steroids. Following discontinuation of medical therapy for hypoglycemia, her blood glucose ranged from 130 to 150 mg/dL, and the patient was transferred out of the MICU to a medical floor for observation without recurrence of hypoglycemia.