INTRODUCTION: The effects of caffeinated alcoholic beverages on patients with chronic medical conditions are not well documented. We present a case of a type I diabetic with intoxication from caffeinated alcoholic beverages.
CASE PRESENTATION: A 53-year-old man was brought to the emergency department by ambulance after being found unresponsive and surrounded by empty cans of the caffeinated alcoholic beverage 4 Loko. The patient had a history of type I diabetes mellitus, with multiple admissions to this institution for diabetic ketoacidosis. The patient was last seen 3 days prior to his presentation. On arrival to the emergency department the patient was obtunded and unable to provide history. The patient later reported that he drank approximately six 24-oz cans of 4 Loko before he lost consciousness. The patient’s past medical history was significant for type I diabetes mellitus, hypertension, hyperlipidemia, and substance abuse. He had a history of alcohol abuse and occasionally used marijuana. His reported home medications included insulin glargine, insulin aspart and lisinopril. On physical examination, the patient was obtunded on arrival to the emergency department and required endotracheal intubation with mechanical ventilation. He was afebrile, BP was 101/42, and HR was 128. His pupils were round and reactive with intact corneal reflex. His mucous membranes were dry, with an endotracheal tube in place. His lungs were grossly clear to auscultation bilaterally. His heart sounds were tachycardic but regular, with no murmurs, rubs or gallops. His abdomen was soft and non-tender. He had no clubbing, cyanosis or edema in his lower extremities. His laboratory data included a hemoglobin of 10.9 gm/dL, white blood count was 17.2 k/uL, and platelet count was 234 k/uL. His sodium was 124 mmol/L, potassium was 9.3 mmol/L, chloride was 87 mmol/L, bicarbonate was 3 mmol/L, BUN was 64 mg/dL, creatinine was 4.44 mg/dL, and blood glucose was greater than 2400 mmol/l. He was noted to have a large amount of serum ketones in his blood, and a lactic acid of 5.3 mmol/L. His chest x-ray showed a normal cardiac and mediastinal silhouette, with proper placement of endotracheal tube and clear lung fields. His serum osmolality, measured after volume resuscitation was initiated, was 384 mosmol/KG, but his serum alcohol level was non-detectable and his volatile alcohol screen was negative. His EKG showed the dynamic changes of widening of the QRS complexes and inversion of the T waves in the precordium. The patient was admitted to the intensive care unit and treated with intravenous insulin, sodium bicarbonate and aggressive intravenous fluid administration. His metabolic acidosis and hyperglycemia quickly improved, and his EKG normalized without hemodialysis. He was liberated from mechanical ventilation within 24 hours of admission. His hospital course was complicated by alcohol withdrawal, which was treated with lorazepam. He was discharged to home after refusing rehabilitation on hospital day #5.
DISCUSSION: The use of caffeinated alcoholic beverages and other non-alcoholic energy beverages has been increasing since they were first introduced approximately 20 years ago. Some studies have shown an increasing amount of risk taking behavior among individuals using alcoholic energy drinks. One study showed a 3-fold increased risk of leaving a bar highly intoxicated and a 4-fold increased risk of intending to drive in comparison with those who did not consume alcoholic drinks mixed with energy drinks. 4 Loko is just one example of a caffeinated alcoholic beverage; the alcohol content ranges from 11-12%, with 660 calories and 60 grams of sugar. 4 Loko has currently been banned in Utah, Michigan, Oklahoma, New York, and Washington. Since evaluation by the FDA, Phusion Products (the makers of 4 Loko) has removed caffeine, taurine, and guarana from their drinks. There have been no studies evaluating the side effects of these beverages on individuals with chronic illnesses, in adolescents, or in young adults. We hypothesize that our patient's high glucose load and caffeine intake allowed for excessive alcohol consumption, which induced loss of consciousness, prolonged time without insulin, and diabetic coma.
CONCLUSIONS: The use of caffeinated alcoholic beverages in those with chronic illnesses has not been studied, and their side effects may be more pronounced in these particular patients.
Reference #1 Thombs DL, O’Mara RJ, Tsukamoto M et al. Event-level analyses of energy drink consumption and alcohol intoxication in bar patrons. Addictive Behaviors; 35 (2010):325-330.
Reference #2 O'Brien, M. C., McCoy, T. P., Rhodes, S. D.,Wagoner, A., &Wolfson, M. (2008). Caffeinated cocktails: Energy drink consumption, high-risk drinking, and alcohol-related consequences among college students. Academic Emergency Medicine, 15, 453−460.
Reference #3 Press Release. Update regarding our reformulated products. Avaliable at: http://www.phusionprojects.com/media_reformulationupdate.html
DISCLOSURE: The following authors have nothing to disclose: Kyle Brownback, Krishna Rangarajan, Steven Simpson
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