Toxicology

For symptomatic patients or blood glucose less than 70 mg/dL, treat with glucose:

Conscious patients: Administer 8 oz of an oral carbohydrate (such as juice, non-diet sodas, or milk)

or oral glucose tablets or gels.

Unconscious patients: Administer intravenous dextrose, 0.5–1 g/kg

Repeat doses may be required; consider a continuous infusion of dextrose if needed. Glucose

concentrations should be monitored often (every 15–60 minutes) until stable.

Octreotide

Mechanism of action is a somatostatin analog that inhibits the secretion of insulin.

Primarily studied in sulfonylurea overdose, but considered a treatment option for all oral

hypoglycemic toxic exposures

Administer 50 mcg subcutaneous or intravenous, followed by 50-mcg doses every 6 hours.

Intravenous dextrose infusion should be slowly tapered off.

Sodium bicarbonate

Indicated for severe metformin-associated lactic acidosis

1–2 mEq/kg or 50–200 mEq of 8.4% sodium bicarbonate intravenously

Glucagon

Mechanism of action is stimulation of gluconeogenesis.

May trigger additional insulin secretion, leading to a secondary hypoglycemia

May provide benefit in prehospital settings when oral or intravenous options are not available, but

is not routinely recommended

exposures

Hemodialysis or continuous renal replacement therapy may be necessary to enhance metformin

clearance in severe cases.

Regular assessment of vital signs and mental status (Emerg Med J 2006;23:565-7)

70 mg/dL.

Measure BP hourly, especially after octreotide administration.

Patient Case

cardiac step-down unit. The patient was found unconscious, and, on investigation, it was discovered that

he had received a glyburide 20-mg tablet 1 hour earlier that was meant for another patient. The patient has

stable vital signs, but his point-of-care blood glucose concentration is 37 mg/dL. Which intervention is most

appropriate at this time?