Budesonide-Induced Hyperosmolar Hyperglycemic State Following Transjugular Intrahepatic Portosystemic Shunt

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