8083 Challenging Management of Diazoxide as a Double-Edged Sword in an Adult Patient with Recurrent Hypoglycemia

Disclosure: J.R. Fredrick: None. J. Qu: None. M. Endo: None. Introduction: An insulinoma is a rare neuro-endocrine tumor that leads to fasting hypoglycemia with adrenergic, cholinergic, and neuroglycopenic symptoms. Diagnosis can be challenging, especially when imaging is negative for neuroendocrine tumor. To prevent recurrent hypoglycemic episodes, treatment can include dextrose and octreotide or diazoxide. We present a case of a patient who responded well to diazoxide but at higher doses, developed life-threatening side effects. Clinical Case 74-year-old female with history of osteoporosis presented with recurrent hypoglycemia with associated symptoms of dizziness, palpitations, and headaches, improved with food. TSH 1.0ulU/mL (0.4-4.7ulU/mL). Morning cortisol 14ug/dL (n>14ug/dL). Patient underwent a 72-hour fasting test, which showed a point-of-care blood sugar of 47mg/dL. Labs included serum glucose 56mg/dL (70-140mg/dL), c-peptide 5.7ng/mL (0.78-5.19ng/mL), insulin 43.6ulU/mL (3-30ulU/mL), and beta-hydroxybutyrate 0.13mmol/L (0-0.5mmol/L). Screening was negative for insulin antibodies and presence of hypoglycemic agents. She became dependent on a dextrose infusion to maintain blood sugars. Magnetic resonance imaging of abdomen was negative for any lesion. Octreotide did not resolve the hypoglycemia. Diazoxide was started, with dose titrated up to 175mg three times daily with decreasing dextrose infusion requirements. However, she developed hypoxic respiratory failure, which was felt due to atelectasis or fluid overload, treated with mild diuresis and incentive spirometry. In the coming days, this escalated to requiring high-flow nasal cannula. Diazoxide was discontinued, and she returned to a dextrose infusion to prevent hypoglycemia. Dotatate scan was completed, revealing a focal intense dotatate tracer uptake within the pancreatic tail. This was followed by magnetic resonance cholangiopancreatography, which confirmed an arterially enhancing diffusion restriction lesion in the pancreatic tail and found several small hyper-vascular liver lesions, primarily hemangiomas, with two lesions indeterminate. The patient was weaned off oxygen and underwent distal pancreatectomy. Pathology confirmed a neuroendocrine tumor. She remained without a dextrose infusion after surgery with no recurrence in hypoglycemia and was discharged 3 days later. Conclusion: Diazoxide is known to improve recurrent hypoglycemia for patients evaluated for hyperinsulinemia. However, caution should be made due to life threatening side effects, including pulmonary edema and severe hypoxic respiratory failure. More expansive literature evaluating these risks would be beneficial(1). Reference 1. Chen, X., Feng, L., Yao, H., et al. Efficacy and safety of diazoxide in treating hyperinsulinemic hypoglycemia: A systemic review and meta-analysis. PLoS One. 2021 Feb 11;16(2):e0246463. Presentation: 6/3/2024