hypoglycemic agents rama b. rao, m.d. bellevue hospital center/nyumc new york, n.y
TRANSCRIPT
Glycemic Control Agents
• Insulin
• Sulfonylureas
• Meglitinides: Repaglinide
• Biguanides: Metformin
• Thiazolidinediones: Pioglitazone Glucosidase inhibitors
HYPOGLYCEMIA
• Hunger/Anxiety
• Focal neurological deficits
• Confusion
• Seizures
• Coma
• Hypothermia
Glycogen
Glucose
LIVER CELL
Storage
I
P
Pyruvate
Kreb’s ATP
EPINEPHRINEGLUCAGON
Oxidative
CyclePhosphorylation
SULFONYLUREA INDUCED HYPOGLYEMIA
• Administration of glucose for acute correction
• Decontamination
• Nutrition, IV access
• Admission
SULFONYLUREAS
• Monitor potassium, phosphate
• Urinary alkalinization for chlorpropamide
• Octreotide for refractory hypoglycemia
• Observation for at least 12 hours after last dose octreotide
Octreotide Dosing
• Adults: 50 g subcutaneously every 6 hours
• Children: 4-5 g/kg/day subcutaneously divided every 6 hours, with maximum not exceeding the adult dose
INSULIN
• Oral exposure is benign
• Parenteral Exposures – Unpredictable in overdose– May be dependent upon quantity injection– Formulation
• Treatment: nutrition, supplemental glucose infusion
HYPOGLYCEMICS: MANAGEMENT
• Identify and treat hypoglycemia
• Admission especially if brought to coma or seizure
• Nutrition– Consider enteral infusion of feeds via NG Tube
• Monitor electrolytes
GLUCOSE ADMINISTRATION
• Adults– D50W 1 gram/kg
• Children– D25W 0.5-1 gram/kg
– D10 W 0.5-1 gram/kg in neonates
• Infusion of D10 W at a total of 1 gram/kg/hr
• Monitor potassium
METFORMIN
• Rarely causes true hypoglycemia
• Adverse reaction– Lactic acidosis only in patients with renal
insufficiency or shock states.– Treatment of lactic acidosis: hemodialysis
• Caveat: Co-ingested substances
OTHER AGENTS AFFECTING CARBOHYDRATE METABOLISM
• Ethanol
• Beta adrenergic antagonists
• Unripened ackee fruit
• Valproic acid
• Salicylates
• Pentamidine
• Quinidine
• Disopyramide
Glycogen
Glucose
LIVER CELL
Pyruvate
Oxidative
ATP
Lactate
Phosphorylation
NAD+
NADH+H+
ETHANOL
Acetate
ALPHA CELL OF PANCREAS
GLUCAGON
DecreasedGlucose
Catecholamines, Amino acids
BETA ADRENERGICANTAGONISTS
Ca2+
PANCREAS: BETA ISLET CELL
Insulin
++ +++
Membrane depolarization
PENTAMIDINEALLOXAN
STREPTOZOCIN