0071643192.pdf

TOXICOLOGY

A 72-year-old male presents to the ED via EMS for weakness and altered

mental status. He has a history of dementia and diabetes. EMS found bot-

tles of metformin and acarbose in the bathroom. Physical examination

reveals a finger stick of 48, sinus tachycardia, and sweaty skin. The patient is

awake, but confused. Which of the drugs found in his house is likely responsible

for his hypoglycemia?

Neither biguanides nor α-Glucosidase inhibitors cause hypoglycemia. Consider

insulin, sulfonylureas, or other nontoxicologic causes of hypoglycemia.

DIABETES MEDICATIONS

Sulfonylureas

Agents include

■ Glipizide
■ Glyburide

MECHANISM/TOXICITY

■ ↑Secretion of preformed insulin from pancreatic βcells→hypoglycemia
(primary mechanism).
■ Hepatic or renal impairment and drug interactions may be inciting event.

SYMPTOMS/EXAM

■ Most agents require 8 hours to reach peak effect.
■ Symptoms of hypoglycemia
■ Mental status changes, agitation
■ Headache
■ Focal neurologic deficits or seizures
■ Tachycardia, hypertension
■ Diaphoresis
■ Nausea

DIFFERENTIAL

■ Other causes of hypoglycemia including insulin excess, sepsis, hepatic
dysfunction.

DIAGNOSIS

■ Usually clear from patient’s history and exam
■ Rapid finger-stick glucose can confirm diagnosis of hypoglycemia.

TREATMENT

■ Correct hypoglycemia via dextrose administration.
■ Activated charcoal if recent ingestion and protected airway
■ All patients who become symptomatic should be admitted for 24 hours of
observation regardless of response to treatment.
■ Antidote=octreotide.

Ingestion of a single

sulfonylurea tablet can

produce severe hypoglycemia

in young children.

Octreotide inhibits the release

of insulin from the pancreas

and therefore can be used in

sulfonylurea-induced

hypoglycemia.