Internal Medicine Journal | 2019
To give or not to give: no dearth of explicit guidelines on potentially inappropriate prescribing of non‐steroidal anti‐inflammatory drugs to older adults
Abstract
increased insulin sensitivity, failure of glycogen storage or failure of gluconeogenesis as opposed to hyperinsulinaemic hypoglycaemia. Her hypoglycaemia was managed with 90 g (13 tablespoons) of cornstarch daily, splitting her prednisolone to 2.5 mg bd, and verapamil 80 mg nocte. She was successfully weaned off treatment 3 months after her last infliximab infusion without further hypoglycaemia. A link between inflammation and insulin resistance has been proposed in recent years. In animal models, inhibition of TNF-α, a major pro-inflammatory cytokine, decreases insulin resistance and reduces hepatic gluconeogenesis. Non-diabetic, non-obese patients with inflammatory bowel disease treated with TNF-α inhibitors exhibited a significant reduction in insulin, C-peptide and insulin resistance index. In a prospective study of patients with CD, maintenance infliximab was associated with a constant and significant decrease in fasting blood glucose and glycosylated haemoglobin concentrations. Hypoglycaemia is not widely reported in infliximab safety data registries. Boulton reported recurrent hypoglycaemia in a 55-year-old woman with type 1 diabetes treated with two TNF-α inhibitors (etanercept and adalimumab) for severe rheumatoid arthritis, which resolved upon medication cessation on both occasions, supporting the notion that the effect of TNF-α inhibition on glucose homeostasis is reversible on cessation. The halflife of infliximab is 8–10 days. In our patient, the effects of TNF-α inhibition on glycaemic control lasted 3 months post-dose, which is approximately five half-lives. She has not been re-challenged with TNF-α inhibitors. In summary, our patient had protracted recurrent symptomatic hypoglycaemia post-infliximab infusion persisting up to 3 months post-infusion, requiring treatment with cornstarch therapy, oral glucocorticoid and verapamil to maintain euglycaemia. Given the increasing use of TNF-α inhibitors, healthcare professionals need to be aware of this uncommon, yet significant adverse effect.