Hypoglycemic Agents

Physiologic
• Cirrhosis
• Alcoholism
• Hemodialysis
• Pregnancy
• Sepsis
• Shock
• Gastric surgery
• Anorexia
• Endocrine disorders

Medications
• Insulin
• Sulfonylureas
• Antidiabetics
• Beta blockers
• Quinidine
• Salicylates
• Valproic acid
• Venlafaxine

Advanced Age
Polypharmacy
Recent Medication Change
Restricted Diet
Renal or Hepatic Disease

Neurogenic:
• Sweating
• Palpitations
• Tachycardia
• Tremors
• Anxiety
• Hunger
• Irritability
• Tingling

Neuroglycopenic:
• Confusion
• Drowsiness/Lethargy
• Unable to follow commands
• Inappropriate behavior
• Headache
• Blurred vision
• Cool skin
• Unconsciousness
• Seizure
• Coma

15 g fast acting carbohydrates

Wait 15 minutes and check BG again

Call 911 if BG remains < 70 mg/dL

Dextrose
• Dose: 0.5 – 1 g/kg IV
• Maximum peripheral concentrations:
• Adult: Dextrose 50%
• Children: Dextrose 25%
• Infants: Dextrose 10%
• ”One amp” D50W = 25 g dextrose
• Adverse effects: hypokalemia, hypophosphatemia

Glucagon
• MOA: mobilizes glycogen from liver to cause catecholamine release
• Dosing
• IM/IV/SQ: 1 mg
• IN: 3 mg into one nostril
• Repeat dosing in 15 minutes if needed
• Duration of effect ~30 minutes
• Adverse effects: nausea/vomiting

Regulates metabolism of carbohydrate, protein, and fats
Stimulates hepatic glycogen synthesis
Promotes hepatic synthesis of fatty acids
Increased protein synthesis and increased glycogen synthesis at skeletal muscle

Formulations with delayed onset, prolonged MOA can lead to delayed and prolonged hypoglycemia
Depot effect when administered IM or SQ
Poor absorption due to poor perfusion in hypoglycemic states
Finite number of insulin receptors in body

ABC’s
• Airway, Breathing, Circulation

Correct Hypoglycemia
• D50W 0.5-1 g/kg IV
• Glucagon IM if no IV access

Decontamination
• Case reports of surgical excision of insulin injection site

Stimulate insulin release from the pancreatic beta cells
Reduce glucose output from the liver
Insulin sensitivity increased at peripheral target sites

Long durations of action leading to long periods of hypoglycemia
Delayed onset of hypoglycemia
Failure of counterregulatory mechanisms over time

ABC’s
• Airway, Breathing, Circulation

Gastric Decontamination
• Activated charcoal

Correct hypoglycemia
• Octreotide
• Use of dextrose transient, often stimulates insulin release from pancreas

• Removal of the patient from the source of toxicity via removal of the toxin from the body
• Activated charcoal in awake patients with intact airway
• Most effective within 1 hour of ingestion at a 10:1 charcoal:toxin ratio
• Typical single dose range 25-100 g PO
• Adverse effects: vomiting, constipation
• Sulfonylureas: high affinity to activated charcoal

• Somatostatin analog: binds to somatostatin receptor on Ca2+ channel of β islet cells of
pancreas → inhibits calcium entry into cell → inhibits insulin release
• Indicated in recurrent hypoglycemia due to sulfonylurea ingestion to reduce ongoing glucose-stimulated insulin release

• T1/2 of 1.5 hours, peak effect within 30 minutes, duration ~24 hours
• Shown to decrease episodes of recurrent hypoglycemia, reduce overall dextrose requirements
• Dosing: 50-100 mcg SQ or IV, can be repeated in 6 hours
• Continuous infusion: 125 mcg/hr x 24 hours
• Adverse effects: injection site pain, GI upset

Decreases hepatic glucose production
Decreases intestinal absorption of glucose
Increases peripheral glucose uptake and utilization to improve insulin sensitivity

Renal dysfunction
Advanced age
Alcohol abuse
Sepsis
Administration of contrast media

ABC’s
• Airway, Breathing, Circulation

Sodium bicarbonate IV infusion
• Critically ill patients, severe acidosis

Hemodialysis
• Moderately dialyzable
• Large volume of distribution

• Caution with initiation of continuous infusion of dextrose – can potentiate further insulin release from pancreas
• D50W bolus in recurrent hypoglycemia episodes followed by infusion of D5W
• Infusion with hypertonic D10W as needed to maintain serum glucose goal of 100-150 mg/dL
• Feeding with carbohydrates and proteins
• Glucose monitoring q1-2hrs following initial stabilization, q4-6hrs with
maintained stabilization
• Monitor for hypophosphatemia, hypokalemia and replete as necessary

GLP-1 Receptor Agonists (tides)
DPP-4 Inhibitors (gliptins)
SGLT-2 Inhibitors (gliflozins)
TZDs (glitazones)