Hypoglycemia can present with altered mental status, coma, seizure, sinus tachycardia, afib, PVCs, hypokalemia, hypothermia 

ALWAYS check poc glucose! 

Insulin 

-can have delayed and prolonged hypoglycemia 

Rapid acting (aspart, lispro) - onset 15-30m, duration up to 5h

Short acting (regular) - onset 30-60m, duration 5-8h

Intermediate acting (NPH) - onset 1-2h, duration 18-24h

Long acting (detemir, glargine) - onset 1-1.5h, duration 24h 

Sulfonylureas (stimulate insulin release) 

-delayed and prolonged hypoglycemia 

Glimepiride, glipizide, glyburide - duration 24h

Exertion 80% renal - half life increased in AKI or CKD

Non-dialyzable

*Risk of recurrent hypoglycemia* 

*Initially treat with dextrose 0.5-1g/kg hypertonic dextrose (D50W adult, D25W children) 

Transient increase in glucose conc then recurrent hypoglycemia d/t insulin release 

AVOID glucagon if have IV access - can stimulate the release of insulin 

AVOID dextrose infusion - risk recurrent hypoglycemia 

If patient alert, FEED them 

*Octreotide (somatostatin) - inhibits glucose-stimulated beta cell insulin release 

Fewer recurrent hypoglycemic episodes and less dextrose required 

Adult dose: 50mcg SQ q6h

Metformin (biguanide) 

Low likelihood of hypoglycemia 

Duration 12-24h

Absorbed in the GI tract within 2 hours 

Renal clearance (decreased renal clearance w/ increase Cr) 

Type B lactic acidosis - toxin induced impairment of cellular metabolism 

Supportive care

IV sodium bicarbonate if serum bicarb < 5 meq/L

Hemodialysis 

Reference: 

Bosse GM. Antidiabetics and Hypoglycemics/Antiglycemics. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank's Toxicologic Emergencies, 11e New York, NY: McGraw-Hill