Medical Care

Prehospital Care

The main goal in oral hypoglycemic agent exposure is supportive care, which includes airway, breathing, and circulation.

Intravenous administration of glucose rapidly resolves the effects of hypoglycemia. Its onset is quicker than oral administration of sugar, and it is safer in patients with a depressed mental status who should not take anything by mouth for fear of aspiration. Glucagon is helpful and can be administered intravenously, intramuscularly, or subcutaneously. Glucagon is particularly useful in the intramuscular mode when intravenous access cannot be obtained immediately.

Emergency Department Care

Generally, all symptomatic patients who present with hypoglycemia need admission to the hospital in a monitored setting. Patients who remain asymptomatic and who do not develop hypoglycemia in the first 8-12 hours may be discharged safely home. However, the data from one study suggest that because accidental ingestion of sulfonylurea results in delayed and often prolonged hypoglycemia, admission for at least 16 hours is recommended, with frequent glucose monitoring.^[24]

At minimum, patients need intravenous access. If the patient is lethargic, then oxygen, continuous cardiac monitoring, and pulse oximeter are indicated. Until the patient totally regains normal mental status, do not administer anything by mouth.

Administer intravenous glucose to all patients with hypoglycemic symptoms. Depending on the amount of the drug and its half-life, patients may require intravenous glucose administration for anywhere from several hours to several days. If patients do not respond to continuous glucose administration with supplemental boluses, then octreotide or diazoxide can be administered.

Ipecac is not recommended because of the possibility of aspiration in patients with a depressed mental status.

Administer activated charcoal as soon as possible, preferably within 1 hour of ingestion. However, most unintentional pediatric exposure involves the ingestion of only one or two tablets of sulfonylureas, and no data indicate that gastric lavage or administration of activated charcoal has any benefit in these cases.

Multiple doses of activated charcoal have been suggested in patients with glipizide overdose because this hypoglycemic agent has an enterohepatic circulation.

Hemodialysis is not indicated because most sulfonylureas have high protein binding.

A child in whom ingestion of any first-generation sulfonylurea (eg, chlorpropamide, acetohexamide, tolbutamide, tolazamide) is suspected should be admitted to the pediatric ward for at least 24 hours of observation, regardless of initial symptoms.

A child in whom ingestion of a second-generation sulfonylurea (eg, glyburide, glipizide, glimepiride) is suspected may be discharged safely home if the patient remains asymptomatic and euglycemic for 8-12 hours. If the patient is lethargic, comatose, or has refractory seizures, admit the patient to the intensive care unit.

Consultations

Contact a regional poison control center for assistance.

Consult a psychiatrist for all suicidal cases. Notify the Department of Social Services of suicide attempts as well as cases of possible neglect and inappropriate child supervision.^[25]

Medication

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Normal hypoglycemic counterregulation.

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Table. Sulfonylurea exposures reported to the American Association of Poison Control Centers' National Data Collection System from 2006-2021

Table. Sulfonylurea exposures reported to the American Association of Poison Control Centers' National Data Collection System from 2006-2021

Year	Exposures	< 6 Years	≥6 Years	Unintentional Exposures	Overall Mortality*	Pediatric Mortality
2006	1951	974	903	1647	1	0
2007	1975	991	890	1666	0	0
2008	1850	987	808	1571	0	0
2009	1769	922	769	1515	1	0
2010	1712	898	745	1453	0	0
2011	1687	804	807	1404	1†	-
2012	1753	850	798	1449	1†	-
2013	1590	778	762	1340	0	0
2014	1584	778	769	1316	2	0
2015	1659	807	852	1413	2	0
2016	1582	677	905	1295	2†	-
2017	1471	693	778	1240	2†	-
2018	1512	613	899	1199	1†
2019	1370	570	800	1113	0
2020	1189	482	707	957	1†
2021	1084	410	674	844	2†
*Overall mortality includes adult and pediatric cases † Patient age not noted

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Author

David Tran, MD Attending Physician, Department of Emergency Medicine, North Shore-LIJ Plainview Hospital

David Tran, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Received salary from Merck for employment.

Chief Editor

Stephen L Thornton, MD Associate Clinical Professor, Department of Emergency Medicine (Medical Toxicology), University of Kansas Hospital; Medical Director, University of Kansas Hospital Poison Control Center; Staff Medical Toxicologist, Children’s Mercy Hospital

Stephen L Thornton, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Additional Contributors

Michael E Mullins, MD Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians

Disclosure: Received stock ownership from Johnson & Johnson for none; Received stock ownership from Savient Pharmaceuticals for none.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Michael Lucchesi, MD, to the original writing and development of this article.