Hypoglycemia After Ingestion of “Street Valium” Containing Glyburide, Alcohol, and Cocaine

Background/Objective Because of their similar appearance and inexpensive cost, sulfonylureas can cause hypoglycemia when substituted for benzodiazepines by the illicit drug market. We present a patient that developed hypoglycemia after ingestion of what she thought to be Valium; work-up revealed sulfonylurea exposure. Case Report A 33-year-old woman was brought to the hospital after being found unresponsive by paramedics with a reported venous blood glucose of 18 mg/dL (reference range 70 – 140 mg/dL). This prompted treatment with 12.5 grams of dextrose administered intravenously. At the hospital, venous blood glucose was 15 mg/dL resulting in intravenous dextrose infusion initiation. Once stable, the patient endorsed a medical history of substance use disorder and anxiety. She reported ingesting two blue pills given to her by a friend as Valium for her anxiety. Laboratory values showed elevated insulin of 47.4 mIU/mL (2.6-24.9), elevated C-peptide of 5.4 ng/mL (1.1-4.4), and glucose of 44 mg/dL (> 70 mg/dL). The patient underwent a 72-hour fasting test. Blood hypoglycemia agent screen was positive for glyburide (> 5 ng/mL). The patient was discharged home in stable condition. Discussion There are approximately 2-5 case reports of hypoglycemia in persons taking illicit drugs containing sulfonylureas. Laboratory values consistent with use of a hypoglycemic agent include elevated insulin and C-peptide, low glucose, and positive hypoglycemia agent screen. Conclusion Sulfonylurea-induced hypoglycemia may lead to clinical sedation, mimicking the effects of benzodiazepines. Sulfonylurea substitution or drug contamination should be suspected when severe hypoglycemia is diagnosed in unresponsive patients suspected of taking illicit drugs.