Adverse Drug Reactions Journal 2019;21(2):144-145

doi:10.3760/cma.j.issn.1008-5734.2019.02.015

Severe hypoglycemia due to misuse of insulin aspart before bedtime in an elderly patient with type 2 diabetes mellitus

Xian DU 1 ; Yinmei YE 1 ; Peihuan SUN 1 ; Jiangxia CAI 1 ; Xinchun YAN 1

Affiliations

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Keywords

Insulin; Hypoglycemia; Medication errors

Country

China

Language

Chinese

Abstract

A 77-year-old female patient with type 2 diabetes mellitus mistakenly injected insulin aspart 16 U subcutaneously as glargine insulin before bedtime.One hour later,she developed slow response and paraphasia.Her urgent blood glucose level was 2.8 mmol/L.An Ⅳ injection of 50％ glucose injection 40 ml,mask oxygen absorption,and continuous ECG monitoring were given immediately.Thirty minutes later,her blood glucose level increased to 8.4 mmol/L.The adjusted hypoglycemic regimen was subcutaneous injection of 8,10,and 8 units of insulin aspart 15 minutes before 3 meals,respectively,and glargine insulin 18 U before bedtime.Six days later,her fasting and 2-hour postprandial blood glucose levels were 7.0-8.3 mmol/L and 9.1-10.2 mmol/L,respectively.