SUN-634 Unexpected Low: A Case of Disulfiram Induced Hypoglycemia

Abstract Disclosure: S. Anderson: None. Z. Ahmed: None. K. Bayrakdar: None. T.K. Hor: None. Introduction: Disulfiram treats alcohol use disorder by inhibiting aldehyde dehydrogenase. Recently discovered, disulfiram and its metabolites also bind to and deactivate fructose-1,6-bisphosphatase leading to decreased gluconeogenesis. Clinical case: A 38-year-old female with alcohol use disorder, monoallelic CFTR gene mutation cystic fibrosis, chronic pancreatitis status-post pancreatectomy with failed pancreatic islet cell auto-transplant and subsequent diabetes mellitus on insulin pump presented to the emergency department with severe refractory hypoglycemia 36 hours after starting disulfiram, despite eating and discontinuing insulin administration.On arrival, patient hemodynamically stable but later unresponsive. Labs showed blood glucose (BG) 18 mg/dL (nl 60-99 mg/dL), bicarbonate 21 mmol/L (nl 22-29 mmol/L), ketone 1.1 mmol/L (nl 0-0.6 mmol/L). She responded to infused dextrose 10% with repeat BG 119 mg/dL. Later transitioned to infused dextrose 5%, she became somnolent with BG 30 mg/dL.Prednisone 40 mg PO was then started followed by hydrocortisone 50 mg q12Hr in setting of recurrent severe hypoglycemia ( <20 mg/dL) for treatment of adrenal insufficiency. 9AM cortisol 1.7 ug/dL (nl 3.17-19.4 ug/dL), ACTH 3.9 ng/mL (nl 6-50 pg/mL) and albumin 2.8 g/dL (nl 3.5-5). Hypoglycemic episodes continued despite high-dose steroids and dextrose infusion. Hypoglycemia resolved 48 hours after disulfiram discontinued, allowing for discontinuation of dextrose infusion. Outpatient HPA axis testing showed resolution of adrenal insufficiency with AM cortisol 26 ug/dL; steroids discontinued with no recurrence of hypoglycemia. Pituitary MRI negative for pituitary cause of adrenal insufficiency.We postulate that her severe, refractory hypoglycemia was secondary to disulfiram-induced inhibition of gluconeogenesis in combination with low glycogen stores due to chronic alcohol use. In 2020, research demonstrated previously unknown inhibiting covalent bond between disulfiram and its metabolites and fructose-1,6-bisphosphatase, leading to gluconeogenesis inhibition. Here, history of alcohol use and adrenal insufficiency led to severe refractory hypoglycemia despite glucocorticoids and dextrose infusions. Conclusion: This may be the first reported case of disulfiram-induced hypoglycemia in an adult. Disulfiram should be used in caution in those with labile diabetes. Presentation: Sunday, July 13, 2025