A 68-year-old woman presents to the emergency department after being found at home with confusion and lethargy. Her medical history includes GERD, obesity, non–insulin dependent type 2 diabetes, and depression with prior suicide attempts. Empty bottles of omeprazole, glyburide, and sertraline were found in her home. She is intubated for airway protection. Her admission laboratory test results are notable for a blood glucose of 33 mg/dL, and she is treated with an IV bolus of dextrose 50. Repeat laboratory tests an hour later show blood glucose 52 mg/dL.
Which of the following is most appropriate to treat her hypoglycemia?
A. Glucagon IMCorrect Answer: B
Critically ill patients can be hypoglycemic for numerous reasons, including the effects of medications, ethanol, sepsis, hepatic failure, renal failure, and the cessation of TPN. This patient’s hypoglycemia most likely results from an overdose of glyburide, a sulfonylurea oral hypoglycemic medication. Sulfonylureas act by increasing insulin release from pancreatic beta cells. The initial treatment for all hypoglycemic episodes should be a bolus of glucose, typically 0.5 to 1 g/kg of D50W. If a patient does not have intravenous access for emergent D50 administration, then IM glucagon is an effective alternative—raising blood glucose by promoting glycogenolysis and gluconeogenesis. After administering an initial glucose bolus, a dextrose infusion is typically required until the underlying cause of hypoglycemia has resolved. However, after sulfonylurea overdose a continuous glucose infusion can stimulate endogenous insulin production, leading to further hypoglycemia. If not recognized this can lead to a cycle of repeated glucose boluses and hypoglycemia episodes. Thus, after sulfonylurea overdose and an initial glucose bolus, octreotide is the preferred treatment. Octreotide is a long-acting somatostatin analog that binds to pancreatic beta cells and blocks insulin secretion. Octreotide can be administered either as an intravenous bolus followed by infusion, or subcutaneously. This patient failed to maintain normoglycemia after an initial D50 bolus, and starting a glucose infusion would likely contribute to further insulin release and repeated hypoglycemia. This patient has a functioning IV and does not require glucagon IM.
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