Proinsulinoma causing severe hypoglycemia in a patient with type 1 diabetes mellitus

Performance on long delays of delayed response tasks is associated with medial temporal function, a region of the brain affected by severe hypoglycemia. A previous study showed that children with type 1 diabetes mellitus (T1DM) with higher risk for severe hypoglycemia performed worse than controls on long delays of a spatial delayed response (SDR) task. We tested the more specific hypothesis that frequency of severe hypoglycemia would relate to long delay SDR performance. Children with T1DM (n = 51) and controls (n = 32) performed the SDR task with short and long delays. Information was collected on children's past severe hypoglycemia. In children with T1DM, number of past severe hypoglycemic episodes accounted for a significant portion of the variance in long delay SDR after controlling for age and age of onset. This relationship was not seen with short delay SDR or with other tasks (verbal or object memory, attention, motor speed). These results support the hypothesis that severe hypoglycemia has specific, negative effects on memory skills in children. If this relationship is extrapolated to children with higher frequency of severe hypoglycemia, due to longer duration of disease or poorer glucose control, it may affect daily functioning and thus need to be considered in treatment decisions. (JINS, 2003, 9, 740–750.)

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What’s Tramadol Got to Do with It? A Case Report of Rebound Hypoglycemia, a Reappraisal and Review of Potential Mechanisms

January 2018 - Pain Physician ◽

10.36076/ppj/2016.19.e1215 ◽

2016 ◽

Vol 8;19 (8;11) ◽

pp. 1215-1220 ◽

Cited By ~ 1

Author(s):

Charles A. Odonkor

Keyword(s):

Diabetes Mellitus ◽

Adverse Effect ◽

Type 1 Diabetes ◽

Type 1 Diabetes Mellitus ◽

Sacroiliac Joint ◽

Severe Hypoglycemia ◽

Opioid Analgesics ◽

Adverse Effect Profile ◽

Underlying Mechanisms

Background: Tramadol has gained traction as an analgesic of choice among pain practicing physicians. However some concerns regarding a previously unlabeled adverse reaction – hypoglycemia – have cast it in a dim light. Prior reports have noted an associated risk of hospitalization for hypoglycemia after tramadol use, but whether tramadol is the main causal agent is poorly understood and the underlying mechanisms are not well delineated. We present a unique case of rebound hypoglycemia as a variation of the theme of tramadol’s adverse effect profile in a patient with type 1 diabetes mellitus, and reappraise potential mechanisms underlying this underappreciated phenomenon. Case Presentation: A 71-year-old woman presented with right buttock pain and right lateral leg discomfort of 9-month duration. Her physical exam suggested sacroiliac joint (SIJ) etiology, confirmed by magnetic resonance imaging (MRI). She was scheduled for an SIJdiagnostic and therapeutic block and started on tramadol 50 mg 3 times daily on as needed basis. The patient subsequently developed severe hypoglycemia initially resistant to euglycemia restorative interventions with a rebound episode. Hypoglycemia resolved with oral ingestion of high levels of glucose and the patient was taken off tramadol. Fortunately, she did not require hospitalization. Discussion: The clinical scenario described is a case of rebound hypoglycemia after tramadol use in a patient with type-1 diabetes naïve to opioid analgesics. The episodes of hypoglycemia aligned perfectly with the anticipated pharmacodynamic and pharmacokinetic properties of tramadol. The specificity and temporality of events after tramadol use in this patient fulfilled causality criteria. Tramadol may cause rebound hypoglycemia in patients via interference of the intrinsic euglycemia-restoration pathways and a blunted autonomic counter-regulatory response to antecedent hypoglycemia. Its use must be tempered by this underappreciated adverse effect profile. Key words: Tramadol, hypoglycemia, sacroiliac joint arthritis, type 1 diabetes mellitus, serotonin uptake inhibitors, glutamate receptor 4

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