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Gouveri E, Gkouveri A, Popovic DS, Papazoglou D, Papanas N. Intentional Insulin Overdose and Depression in Subjects with and Without Diabetes Mellitus: A Commentary. Diabetes Ther 2024; 15:1845-1854. [PMID: 39046697 PMCID: PMC11330432 DOI: 10.1007/s13300-024-01623-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/09/2024] [Indexed: 07/25/2024] Open
Abstract
Insulin is an essential medication for people with type 1 diabetes mellitus and for some people with type 2 diabetes. Interestingly, insulin abuse has been reported as a mode of suicide, not only among people with diabetes, but also among their relatives, and among medical and paramedical personnel who have access to insulin. The aim of the present commentary was to raise awareness of potential depression-related intentional insulin overdose and its complications, as well as of the diagnosis and treatment of this entity. Insulin overdose may lead to severe and prolonged hypoglycemia, hypoglycemic coma, and death. Moreover, hypokalemia, hypomagnesemia, hypophosphatemia, and elevated liver enzymes are common. Insulin overdose should be suspected among people with diabetes in case of unexplained prolonged hypoglycemia and among people without diabetes who exhibit hypoglycemia and may have access to diabetic medications. The ratio of insulin to C-peptide helps distinguish exogenous insulin administration from endogenous secretion. The cornerstone of therapy is prompt administration of concentrated glucose infusions for days with simultaneous oral intake, when possible, and intense glucose monitoring to prevent hypoglycemia. Moreover, monitoring of serum electrolyte levels is recommended. Finally, psychiatric evaluation aiming at early identification of depression and suicidality is of paramount importance.
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Affiliation(s)
- Evanthia Gouveri
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | | | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Novi Sad, Serbia
- Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Dimitrios Papazoglou
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece.
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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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The Other Face of Insulin—Overdose and Its Effects. TOXICS 2022; 10:toxics10030123. [PMID: 35324747 PMCID: PMC8955302 DOI: 10.3390/toxics10030123] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
Insulin is the most effective glycemic-lowering drug, and for people suffering from type 1 diabetes it is a life-saving drug. Its self-dosing by patients may be associated with a higher risk of overdose, both accidental and deliberate. Insulin-induced hypoglycemia causes up to 100,000 emergency department calls per year. Cases of suicide attempts using insulin have been described in the literature since its introduction into therapy, and one of the important factors in their occurrence is the very fact of chronic disease. Up to 90% of patients who go to toxicology wards overdose insulin consciously. Patients with diabetes are burdened with a 2–3 times higher risk of developing depression compared to the general population. For this reason, it is necessary to develop an effective system for detecting a predisposition to overdose, including the assessment of the first symptoms of depression in patients with diabetes. A key role is played by a risk-conscious therapeutic team, as well as education. Further post-mortem testing is also needed for material collection and storage, as well as standardization of analytical methods and interpretation of results, which would allow for more effective detection and analysis of intentional overdose—both by the patient and for criminal purposes.
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Zhang JY, Shang T, Klonoff DC. Regarding a successful treatment with artificial pancreas for a patient who attempted suicide using a high-dose insulin s.c. injection. Acute Med Surg 2020; 7:e567. [PMID: 32995021 PMCID: PMC7503089 DOI: 10.1002/ams2.567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 11/14/2022] Open
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