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Manetti AC, Visi G, Spina F, De Matteis A, Del Duca F, Turillazzi E, Maiese A. Insulin and Oral Hypoglycemic Drug Overdose in Post-Mortem Investigations: A Literature Review. Biomedicines 2022; 10:2823. [PMID: 36359343 PMCID: PMC9687110 DOI: 10.3390/biomedicines10112823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/20/2022] [Accepted: 11/03/2022] [Indexed: 11/15/2023] Open
Abstract
Background and Objectives: Insulin and oral hypoglycemic agents are drugs widely used in the world population due to their therapeutic effects on diabetes mellitus. Despite these benefits, they can also cause accidental or voluntary drug overdose. This review aims to evaluate post-mortem investigations in cases of suspected hypoglycemic drug overdose. Materials and Methods: We performed a comprehensive search using the Preferred Reporting Items for Systematic Review (PRISMA) standards; we systematically searched the PubMed, Science Direct Scopus, Google Scholar, and Excerpta Medica Database (EM-BASE) databases from the point of database inception until August 2022. The following inclusion criteria were used: (1) original research articles, (2) reviews and mini-reviews, (3) case reports/series, (4) and only papers written in English. Results: Thirty-three scientific papers, including original research articles, case reports, and case series, fulfilled the inclusion criteria. A total of 109 cases of insulin or hypoglycemic drug overdose were found. There were 71 cases of suicide (65%), 25 cases of accidental poisoning (23%), and 13 cases of homicide (12%). The most commonly used drug was insulin (95.4%). Autopsy and post-mortem examinations were performed in 84 cases, while toxicological investigations were performed in 79 cases. The most common gross findings in the autopsy were pulmonary edema (55.7%) and congestion (41.8%), while the most common histological finding was neuronal depletion or necrosis (29.1%). Conclusions: In the suspicion of death from insulin or overdose from oral hypoglycemic agents, autopsy findings may be nonspecific, and the search for injection marks can be positive at the external examination. Significant post-mortal alterations can interest biological samples and an early autopsy investigation is recommended.
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Affiliation(s)
- Alice Chiara Manetti
- Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, via Roma 55, 56126 Pisa, Italy
| | - Giacomo Visi
- Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, via Roma 55, 56126 Pisa, Italy
| | - Federica Spina
- Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, via Roma 55, 56126 Pisa, Italy
| | - Alessandra De Matteis
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
| | - Fabio Del Duca
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
| | - Emanuela Turillazzi
- Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, via Roma 55, 56126 Pisa, Italy
| | - Aniello Maiese
- Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, via Roma 55, 56126 Pisa, Italy
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Toxicological and Biochemical Analyses of an Autopsy Case Involving Oral Overdose of Multiple Antidiabetic and Antihypertensive Drugs. Case Rep Med 2018; 2018:5864658. [PMID: 30595699 PMCID: PMC6286784 DOI: 10.1155/2018/5864658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/05/2018] [Accepted: 11/04/2018] [Indexed: 11/17/2022] Open
Abstract
Oral antidiabetics can cause fatal hypoglycemia; although they can be chemically identified and quantified, biochemical investigations are important for assessing the biological consequences of an overdose. Such cases of overdose involving oral antidiabetics may involve other drugs for treating lifestyle-related diseases, particularly antihypertensives. Here, we report a toxicological and biochemical investigation of drugs and biochemical profiles in a fatal overdose involving multiple oral antidiabetics and antihypertensives. A 55-year-old woman died about 2 days after the ingestion of around 110 tablets of antidiabetics and antihypertensives that had been prescribed for her husband. A forensic autopsy and histological analysis demonstrated no evident pathology as the cause of death. A toxicological analysis suggested hypoglycemia and an overdose of antihypertensives as well as the retention of antidiabetics and diuretics in the pericardial fluid. A relatively low pericardial amlodipine concentration was observed, which may have been the result of its long half-life (slower distribution and reduction rate) and/or possible affinity with the myocardium. In addition, a biochemical analysis indicated hypoglycemia, without increased serum insulin and C-peptide, but with increased glucagon levels, as the possible influence of glibenclamide overdose. These observations suggest the usefulness of a combination of toxicological and biochemical analyses in postmortem investigations involving a fatal overdose of such drugs.
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Kumar A, Kumar A, Murty OP, Gupta VP, Das S. A rare case of homicidal insecticide (organochloro compound) poisoning by intraperitoneal injection. MEDICINE, SCIENCE, AND THE LAW 2012; 52:231-233. [PMID: 22623712 DOI: 10.1258/msl.2012.010027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We report a case of a 52-year-old businessman who was allegedly injected with organochloro compound (OC) in his abdomen by his business rivals by means of a surgical needle and a syringe. Homicide by OC injection via an intraperitoneal route has not been reported in the literature. Postmortem findings along with the toxicology report have been discussed particularly in view of the mode of poison administration with a review of literature.
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Ribeiro DS, Lopes JA, Santos JL, Prior JA. Exploiting adsorption and desorption at solid–liquid interface for the fluorometric monitoring of glibenclamide in adulterated drinks. Anal Chim Acta 2012; 721:97-103. [DOI: 10.1016/j.aca.2012.01.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 01/17/2012] [Indexed: 11/29/2022]
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Ribeiro DS, Prior JA, Taveira CJ, Mendes JM, Santos JL. Automatic miniaturized fluorometric flow system for chemical and toxicological control of glibenclamide. Talanta 2011; 84:1329-35. [DOI: 10.1016/j.talanta.2011.02.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 02/09/2011] [Accepted: 02/25/2011] [Indexed: 11/26/2022]
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Rowden AK, Fasano CJ. Emergency Management of Oral Hypoglycemic Drug Toxicity. Emerg Med Clin North Am 2007; 25:347-56; abstract viii. [PMID: 17482024 DOI: 10.1016/j.emc.2007.02.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
There are several classes of oral diabetes medications available in the United States, including sulfonylureas, meglitinides, biguanides, glitazones, and alpha-glucosidase inhibitors. These different classes have various mechanisms of action, giving each class a unique potential for toxicity that necessitates a distinct approach to evaluation, treatment, and disposition of each class of drug. The practicing emergency physician must have an understanding of these differences to safely care for patients exposed to these medications.
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Affiliation(s)
- Adam K Rowden
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA.
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Abstract
Under physiologic conditions, glucose plays a critical role in providing energy to the central nervous system. A precipitous drop in the availability of this substrate results in dramatic symptoms that signal a medical emergency and warrant immediate therapy aimed at restoring plasma glucose to normal levels. A systemic approach to the differential diagnosis is useful in identifying the cause of hypoglycemia. Once established, a specific and/or definitive intervention that addresses that underlying problem can be implemented. In most cases, this systemic approach to diagnosis and therapy is rewarded with a good outcome for the patient.
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Affiliation(s)
- Jean-Marc Guettier
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD 20892, USA.
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Spiller HA, Pfiefer E. Two fatal cases of selenium toxicity. Forensic Sci Int 2006; 171:67-72. [PMID: 16891071 DOI: 10.1016/j.forsciint.2006.06.077] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 06/19/2006] [Accepted: 06/29/2006] [Indexed: 11/21/2022]
Abstract
Two patients, a 36-year-old female and a 36-year-old male, separately experienced new onset nausea, vomiting, diarrhea, abdominal pain, muscle weakness and pallor. Over a period of 14-16 h these symptoms continue and progress to include hypotension refractory to therapy, pulmonary edema and cardiovascular collapse. Autopsies show hemorrhagic pulmonary edema, splenomegaly and lack of anatomical cause for sudden death. Postmortem analysis, in one case post-embalming and exhumation, revealed elevated selenium concentrations and a determination of the cause of death. These two cases present several important features associated with selenium toxicity, two of which are previously unreported: (1) selenium as a potential homicidal agent, (2) the toxidrome and time frame of selenium toxicity, (3) selenium determination in exhumed, embalmed tissues, (4) postmortem urinary selenium concentration, and (5) decrease in tissue concentrations over time.
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Affiliation(s)
- Henry A Spiller
- Kentucky Regional Poison Center, PO Box 35070, Louisville, KY 40232-5070, USA.
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