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Abbreviations: ADA, American Diabetes Association; SLE, systemic lupus erythematosus; SMBG, self-monitored blood glucose; SSZ, sulfasalazine.
Salicylates are therapeutic agents clinically useful in treating inflammatory bowel diseases and arthropathies. These drugs have also demonstrated glucose-lowering effects in type 2 diabetes (1-2). Sulfasalazine (SSZ) is a compound that is cleaved in vivo to 5-aminosalicylic acid (a salicylate) and sulfapyridine (a sulfonamide antibiotic). We report a case of a patient with systemic lupus erythematosus (SLE) and type 2 diabetes on high-dose insulin therapy, who after initiating SSZ experienced recurrent severe hypoglycemia and eventually achieved normoglycemia without the need for diabetes medications. After caring for the index patient, and then two others manifesting similar metabolic responses to SSZ, we conducted a systematic chart review to evaluate glycemic effects of SSZ in a cohort of diabetic patients.
HISTORY AND EXAMINATION- A 37-year-old woman with SLE, iron-deficiency anemia, metamphetamine usage, and a 1-year history of type 2 diabetes was referred to the Santa Clara Valley Medical Center (SCVMC) diabetes clinic for treatment of severe hyperglycemia. She took 100 units of insulin daily (NPH 35 units b.i.d., regular 10 units t.i.d.), yet her self-monitored blood glucose (SMBG) values consistently exceeded 16.7 mmol/l, and she experienced polyuria/dipsia and blurry vision. Other medications were prednisone 7.5 mg/day and hydroxychloroquine. On examination, the patient was cachexie, weighing 44 kg. Laboratory evaluation revealed normal thyroid, hepatic, and renal function, with no microalbuminuria. The HbA^sub 1c^ (A1C) value was 12.3%. During the next 2 months, insulin doses were gradually increased to 170 units/day, but SMBG values persisted at 13.9-22.2 mmol/l.
The patient subsequently started SSZ (500 mg b.i.d.) for SLE treatment. One month later she was found unresponsive with a blood glucose level of 1.8 mmol/l. Despite decreasing insulin doses to 50 units/day over the next 2 weeks, the patient reported persistent hypoglycemia, with SMBG values <3.9 mmol/l. Insulin was discontinued and glyburide 10 mg b.i.d. was started. Two months later, the patient suffered another severe hypoglycemic episode requiring medical assistance. She then stopped all diabetes medications. Despite a weight gain of >22 kg, the patient's follow-up A1C was 5.0%, and her SMBG ranged...