Severe co-trimoxazole-induced hypoglycaemia in a patient with microscopic polyangiitis

Clinical features, risk factors, diagnosis, and treatment of trimethoprim-sulfamethoxazole-induced hypoglycemia

OBJECTIVE

Hypoglycemia is a sporadic and serious adverse reaction of trimethoprim-sulfamethoxazole (TMP-SMX) due to its sulfonylurea-like effect. This study explored the clinical characteristics, risk factors, treatment, and prognosis of TMP-SMX-induced hypoglycemia.

METHODS

Case reports and series of TMP-SMX-induced hypoglycemia were systematically searched using Chinese and English databases. Primary patient and clinical information were extracted for analysis.

RESULTS

A total of 34 patients were reported from 31 studies (16 males and 18 females). The patients had a median age of 64 years (range 0.4-91), and 75.8% had renal dysfunction. The median duration of a hypoglycemic episode was six days (range 1-20), and the median minimum glucose was 28.8 mg/dL (range 12-60). Thirty-two patients (97.0%) showed neuroglycopenic symptoms, with consciousness disturbance (30.3%) and seizure (24.2%), sweating (18.2%), confusion (15.2%), asthenia (12.1%) being the most common symptoms. Fifteen patients (44.1%) had elevated serum insulin levels, with a median of 31.8 μU/mL (range 3-115.3). C-peptide increased in 13 patients (38.2%), with a median of 7.7 ng/mL (range 2.2-20). Complete recovery from symptoms occurred in 88.2% of patients without sequelae. The duration of hypoglycemia symptoms was 8 hours to 47 days after the intervention. Interventions included discontinuation of TMP-SMX, intravenous glucose, glucagon, and octreotide.

CONCLUSION

Hypoglycemia is a rare and serious adverse effect of TMP-SMX. Physicians should be aware of this potential adverse effect, especially in patients with renal insufficiency, increased drug doses, and malnutrition.

Trimethoprim-sulfamethoxazole-induced refractory hypoglycaemia successfully treated with octreotide

Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly prescribed antimicrobial agent for a wide variety of infections. It is generally well tolerated in a majority of patients; however, serious adverse effects have been described with its usage. Hypoglycaemia is an exceedingly rare but potentially life-threatening side effect of this antimicrobial agent due to its sulfonylurea-like effect. We describe a case of symptomatic, refractory hypoglycaemia secondary to TMP-SMX in a patient being treated for Stenotrophomonas maltophilia bacteraemia, which required treatment with 10 hours of intravenous dextrose (including several 50% dextrose boluses), as well as intramuscular glucagon and octreotide. We reviewed previous case reports described in the literature of TMP-SMX-induced hypoglycaemia, in which renal insufficiency was noted to be a common predisposing risk factor in an overwhelming majority of cases. In refractory cases of TMP-SMX-induced hypoglycaemia, intravenous octeotride may be considered for treatment.