use octreotide for glipizide overdose

This patient has overdosed on glipizide, an oral sulfonylurea, and has recurrent symptomatic hypoglycemia after treatment with IV dextrose. The next most appropriate intervention is to administer octreotide 50 μg subcutaneously. Sulfonylureas stimulate pancreatic islet β cells’ release of insulin. As would be expected, a sulfonylurea overdose results in a hyperinsulinemic state, and the clinical manifestations are from the resultant hypoglycemia. Initial treatment for the hypoglycemia is a bolus of IV dextrose to restore normal blood glucose levels. Further IV boluses of dextrose stimulate endogenous insulin production, resulting in rebound hypoglycemia. This cycle is continued with readministration of IV dextrose.  Octreotide, a synthetic analogue of somatostatin, suppresses insulin release from pancreatic islet β cells, and when octreotide is administered, it breaks the cycle of rebound hypoglycemia. Treatment with octreotide is associated with fewer hypoglycemic episodes, decreased dextrose requirement, and marked reduction in serum insulin and C-peptide concentrations; therefore, octreotide is considered a specific sulfonylurea antidote. The recommended dose of octreotide for adults is 50 μg intravenously or subcutaneously, followed by three additional doses every 6 h. During this time, dextrose infusions should be tapered off, and serum glucose concentrations should be closely monitored. Glucagon increases blood glucose levels by stimulating gluconeogenesis, which may in turn trigger insulin secretion, leading to secondary or rebound hypoglycemia. As glucagon can be administered intramuscularly, it may have a role in the prehospital setting or when IV access is absent. In general, it is not recommended for treatment of hypoglycemia in the setting of a sulfonylurea overdose. It appears likely that more than 2 h have passed since she overdosed; therefore, activated charcoal has limited benefit and is not the next most appropriate intervention.

Renal replacement therapy would be indicated for severe metformin-induced metabolic acidosis and lactic acidosis. Although we do not know what other medications she is prescribed, she does not have an acidosis or an anion gap; thus, renal replacement therapy is not indicated.12345

Footnotes

  1. SEEK Questionnaires ↩

  2. Calello DP, Liu KD, Wiegand TJ, et al; Extracorporeal Treatments in Poisoning Workgroup. Extracorporeal treatment for metformin poisoning: systematic review and recommendations from the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med. 2015;43(8):1716-1730. PubMed ↩

  3. Glatstein M, Scolnik D, Bentur Y. Octreotide for the treatment of sulfonylurea poisoning. Clin Toxicol (Phila). 2012;50(9):795-804. PubMed ↩

  4. Klein-Schwartz W, Stassinos GL, Isbister GK. Treatment of sulfonylurea and insulin overdose. Br J Clin Pharmacol. 2016;81(3):496-504. PubMed ↩

  5. Lheureux PE, Zahir S, Penaloza A, et al. Bench-to-bedside review: antidotal treatment of sulfonylurea-induced hypoglycaemia with octreotide. Crit Care. 2005;9(6):543-549. PubMed ↩