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Case Study: Atypical Antipsychotic Use Associated With Severe Hyperglycemia

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A.T. is a 50-year-old woman who developed acute hyperosmolar crisis. She first presented for primary care 5 months before the event. Medical history was notable for longstanding schizo-affective disorder and hyperlipidemia. She denied a history of diabetes. She reported her medication regimen had not changed in more than 1 year; medications included divalproex (Depakote), gabapentin (Neurontin), olanzapine (Zyprexa), and gemfibrozil (Lopid).

A.T.’s weight was 235 lb. A random plasma glucose was 103 mg/dl. Liver function tests, blood urea nitrogen, and creatinine were also normal. One month before the event, hydrochlorothiazide, 25 mg daily, was started for hypertension, and simvastatin (Zocor) was substituted for gemfibrozil to treat hypercholesterolemia.

One month later, A.T. presented to clinic with 1 day of urinary incontinence but no other symptoms of illness and was hospitalized for severe hyperglycemia. Her weight was 219 lb. Urinalysis showed no white blood cells but was strongly positive for glucose and weakly positive for ketones (trace). Her glucose level was 1,572 mg/dl, and her hemoglobin A_1c (A1C) result was >14%. Her serum sodium was 113 mEq/l, potassium was 4.8 mEq/l, and carbon dioxide (bicarbonate) was 36 mEq/l. A.T. was severely volume-depleted as evidenced by postural hypotension, elevated blood urea nitrogen of 47 mg/dl, and elevated creatinine of 2.5 mg/dl. A semiquantitative blood acetone level was positive at a dilution of 1:8 (reference range is negative). A toxicology screen was negative. No evidence of infection, myocardial ischemia, or other acute illness was found. During the hospital stay, A.T. reported earlier . . . [Full Text of this Article]

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