44 yo F with h/o ESRD on HD and neurosarcoidosis complicated by panhypopituitarism on chronic steroids and thyroid replacement, BIBEMS obtunded. Last seen normal a few hours ago. The patient is hypotensive SBP ~75 and FSBG is undetectably low. The patient’s mental status responds well to D50. She denies exogenous insulin, or other ingestions. Admits to missing HD and to being non-compliant with steroid therapy over the last few days.
There is concern for adrenal crisis, so the patient is given 100mg hydrocortisone, in addition to IV synthroid of for possible myxedema coma. Shortly after HD is initiated, the patient again becomes obtunded. This time her FSBG is normal.
Could one of these medications have been dialyzed out?