79 Case review: Withdrawal of IV glucose therapy for refractory hypoglycaemia in a patient with metastatic insulinoma

<h3></h3> This case report describes the withdrawal of life sustaining treatment for a patient with metastatic insulinoma. Whilst withdrawal of non-invasive ventilation, dialysis or other life sustaining treatment has been well documented there is little research on withdrawal of IV glucose in patients with hypoglycaemia secondary to insulinoma. <h3>Background</h3> A 66 year old man with a background of metastatic insulinoma was admitted to hospital with recurrent hypoglycaemia. He was diagnosed with metastatic insulinoma four years earlier and received Lutetium Dotatate Therapy, which had initially stabilised his disease. Unfortunately as his disease progressed he experienced ongoing hypoglycaemia despite regular dexamethasone. At the point of referral to the specialist palliative care team he was admitted with refractory hypoglycaemia despite increased dexamethasone and continuous IV glucose 10%. He was still waking every three to four hours to eat to maintain his blood sugars. His hypoglycaemic episodes were symptomatic and distressing, including seizures and nausea. A CT scan showed significant disease progression, and the patient made the decision to withdraw from treatment to maintain his blood sugars with the knowledge that he would die as a result. Withdrawal of treatment: A bed was arranged at the local hospice to allow the withdrawal of active treatment in a calm and controlled environment. The patient was anxious about symptomatic hypoglycaemia once he stopped IV glucose and was therefore started on a syringe driver with midazolam to reduce distress and agitation, as well as prevent seizures. A combination of morphine and midazolam was given to maintain comfort and he died within 12 hours of stopping IV glucose. <h3>Discussion</h3> Metastatic insulinoma is rare and there is very little data discussing the withdrawal of active treatment. Parallels can be drawn between this and withdrawal of Non-invasive ventilation, both in the mechanism and effect on relatives or staff.