LAUSR

Learning Objectives: Fluoroquinolones are a commonly prescribed class of broad spectrum antimicrobials used for a variety of bacterial infections given the degree of tissue penetration and oral bioavailability provided. Although rare, levofloxacin has been implicated in causing hypoglycemia. We report a case of severe, refractory hypoglycemia from levofloxacin that was responsive to octreotide. Causality is probable based on the Naranjo scale. Methods: A 73 year-old male with type 2 diabetes, controlled on glipizide, presented to the emergency department after a witnessed seizure at his nursing facility and a reported blood glucose (BG) of 21mg/dL. Laboratory findings were non-contributory except a serum creatinine of 2.52mg/dL. The patient was given multiple boluses of 50% dextrose (D50), started on a 10% dextrose (D10) infusion, and admitted to the intensive care unit. Despite efforts to maintain euglycemia via continued D50 boluses, an increased D10 infusion rate, and glucagon, the patient experienced episodes of rebound hypoglycemia (BG 24-61mg/dL) 18 hours from initial presentation. On further review, it was noted that the patient was recently prescribed a course of levofloxacin for pneumonia. No other medication changes were identified. Due to refractory hypoglycemia despite standard supportive care therapies, octreotide 50 mcg subcutaneously was administered every 6 hours. After the first dose of octreotide, BG levels increased significantly within 3 hours and no further D50 boluses were required. The D10 infusion was conservatively continued for 5.5 hours after the second dose of octreotide. Due to persistent hyperglycemia (BG >250mg/ dL), the infusion was discontinued and a final dose of octreotide was given. The patient had no further complications and was discharged to his nursing rehabilitation facility in stable condition. Results: To the best of the authors’ knowledge, this is the second case report that describes the use of octreotide to treat hypoglycemia caused by levofloxacin in a type 2 diabetic. This case report highlights an important but lesser known adverse effect (AE) of fluoroquinolones. It is essential that clinicians are cognizant of this lesser known AE to ensure prompt recognition and treatment using appropriate adjuncts. Octreotide is a novel and safe therapy to treat refractory hypoglycemia induced by levofloxacin.