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Aortic stenosis — USMLE Step 2 CK MCQ

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HardInternal MedicineAortic stenosisUSMLE Step 2 CK

A 72-year-old woman with stage 4 chronic kidney disease takes glipizide and is found confused with a glucose concentration of 31 mg/dL. She awakens after intravenous dextrose but has two further symptomatic episodes despite a dextrose infusion and supervised meals. C-peptide and insulin concentrations are elevated, and no exogenous insulin is available at home. Which additional treatment is most appropriate?

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Correct answer: B — Administer subcutaneous octreotide with continued glucose monitoring

The best answer is “Administer subcutaneous octreotide with continued glucose monitoring”. Recurrent hypoglycemia after dextrose in a patient taking a renally cleared sulfonylurea reflects continued endogenous insulin release, which additional glucose can stimulate further. Octreotide suppresses pancreatic insulin secretion and reduces recurrent episodes after initial dextrose correction. Glucagon may also stimulate insulin and has limited glycogen-dependent benefit; insulin is harmful, and empiric glucocorticoids do not address the documented hyperinsulinemic mechanism. Prolonged observation is required after octreotide and dextrose are discontinued.

Reference: Journal of Medical Toxicology Review: Treatment of Sulfonylurea and Insulin Overdose: https://pmc.ncbi.nlm.nih.gov/articles/PMC4767194/