Budesonide-Induced Hyperosmolar Hyperglycemic State Following Transjugular Intrahepatic Portosystemic Shunt

Abstract

ABSTRACT: Objective: Recognize a rare endocrinological side effect of a drug, budesonide, which surfaced as a result of a major procedure. Methods: We describe a patient who presented with hyperglycemic hyperosmolar state (HHS) likely as a result of the bypass of first-pass metabolism due to budesonide treatment after a transjugular intrahepatic portosystemic shunt (TIPS) procedure. Results: A 62-year-old female with history of combined variable immunodeficiency complicated by colitis (managed by 9 mg budesonide by mouth daily) and refractory ascites secondary to non-cirrhotic portal hypertension (status post-TIPS 3 weeks prior) presented to the hospital with HHS. Her initial insulin requirements were high but improved after discontinuation of budesonide. She was able to be transitioned to a sliding scale and discharged on metformin. When taken orally, budesonide is subject to high first-pass metabolism resulting in minimal systemic effects. Development of HHS and dramatic insulin requirements within 3 weeks of TIPS with drastic improvement following the discontinuation of budesonide leads us to postulate that this was bypassed, leading to steroid-induced diabetes. Conclusion: The case beckons us to be mindful of procedures that alter drug metabolism and make necessary adjustments to prevent complications. Abbreviations: HHS hyperglycemic hyperosmolar state TIPS transjugular intrahepatic portosystemic shunt