A 68-year-old Caucasian female is brought to the emergency room after she was found in her apartment obtunded with a fingerstick glucose level of 34 mg/dL. Two ampules of intravenous 50% dextrose are administered en route to the hospital. Her past medical history is significant for severe depression, type 2 diabetes mellitus, and osteoarthritis. Her home medications include glyburide and sertraline. Her blood pressure is 155/93 mmHg and her heart rate is 122/min. On examination in the ER, the patient is obtunded and diaphoretic. While she is being examined, she has an episode of generalized tonic-clonic seizures. A repeat blood glucose level is 33 mg/dL. Two ampules of intravenous 50% dextrose are given and the patient is started on 10% dextrose infusion. Which of the following is the best additional therapy for this patient?

Question

A 68-year-old Caucasian female is brought to the emergency room after she was found in her apartment obtunded with a fingerstick glucose level of 34 mg/dL.  Two ampules of intravenous 50% dextrose are administered en route to the hospital.  Her past medical history is significant for severe depression, type 2 diabetes mellitus, and osteoarthritis.  Her home medications include glyburide and sertraline.  Her blood pressure is 155/93 mmHg and her heart rate is 122/min.  On examination in the ER, the patient is obtunded and diaphoretic.  While she is being examined, she has an episode of generalized tonic-clonic seizures.  A repeat blood glucose level is 33 mg/dL.  Two ampules of intravenous 50% dextrose are given and the patient is started on 10% dextrose infusion.  Which of the following is the best additional therapy for this patient?

Quizplus · Accepted Answer

Explanation: This patient has been using the sulfonylurea glyburide for her type 2 diabetes mellitus. Sulfonylureas cause increased insulin secretion, which likely caused this patient's hypoglycemia. The persistence of her hypoglycemia suggests that she took a large dose of the medication, although it is unclear at this time if this was accidental or intentional. The initial treatment with dextrose was appropriate; however, dextrose administration can cause transient hyperglycemia that may elicit an even higher level of insulin secretion and subsequent rebound hypoglycemia. Octreotide is a somatostatin analogue that decreases insulin secretion and should be considered in patients with a large sulfonylurea overdose, particularly if the patient is unable to say how much medication was ingested. (Choice A) Exenatide, a GLP1 analog, is an adjunctive therapy for diabetes mellitus. It is generally used for patients with difficult to control hyperglycemia and rarely results in hypoglycemia. (Choice B) Metoprolol would mask some of this patient's adrenergic symptoms of hypoglycemia and would not treat the underlying problem of increased insulin secretion. (Choice D) Pentazocine is a mixed opioid agonist-antagonist. It should be avoided in opioid-dependent subjects because it can result in rapid withdrawal. (Choice E) Sitagliptin is a dipeptidyl peptide IV inhibitor which is used in the treatment of diabetes mellitus. Educational objective: Dextrose is the first-line treatment for sulfonylurea poisoning. Octreotide is a somatostatin analog that decreases insulin secretion in patients with severe sulfonylurea overdose. References: Octreotide's role in the management of sulfonylurea-induced hypoglycemia. (http://www.ncbi.nlm.nih.gov/pubmed/20352540) Use of octreotide acetate to prevent rebound hypoglycaemia in sulfonylurea overdose. (http://www.ncbi.nlm.nih.gov/pubmed/17652687)

A 68-Year-Old Caucasian Female Is Brought to the Emergency Room