Management of Insulin Icodec (7-Day Acting Insulin) Overdose
An overdose of insulin icodec (7-day acting insulin) causes severe, prolonged hypoglycemia requiring immediate intervention with continuous glucose administration and close monitoring for up to a week due to the ultra-long-acting nature of this insulin formulation.
Clinical Presentation of Insulin Overdose
- Insulin overdose presents with symptoms of hypoglycemia ranging from mild (sweating, tremor, hunger) to severe (altered mental status, seizures, coma) 1
- Long-acting insulin analogs like icodec can cause persistent hypoglycemia lasting significantly longer than their usual duration of action 2, 3
- Mental status changes are the most common serious manifestation, occurring in up to 73% of insulin overdose cases 4
Initial Management
- Immediately administer 50% dextrose IV bolus for severe hypoglycemia (glucose <3.0 mmol/L or altered mental status) 5
- Initiate continuous intravenous infusions of 10% or 20% dextrose to maintain blood glucose between 100-250 mg/dL (5.5-14 mmol/L) 3, 6
- For a 7-day acting insulin like icodec, prepare for prolonged glucose requirements potentially lasting several days to a week 4
- Monitor capillary blood glucose every 15-30 minutes initially, then adjust frequency based on stability 7
Complications to Monitor and Manage
- Hypoglycemia: The primary and most dangerous complication requiring continuous monitoring and treatment 1
- Hypokalemia: Occurs in approximately 49% of insulin overdose cases due to intracellular potassium shift 4, 1
- Target potassium levels of 2.5-2.8 mEq/L to avoid aggressive repletion 7
- Other electrolyte disturbances: Present in 42% of cases and require regular monitoring 4
- Hepatic dysfunction: Occurs in 7% of cases; monitor liver enzymes 4
- Cardiac toxicity: Arrhythmias occur in 9% of cases; cardiac monitoring is recommended 4
- Volume overload: Can occur due to large volumes of dextrose infusion 8
Advanced Management Options for Refractory Cases
- Glucagon: 3-10 mg IV administered slowly over 3-5 minutes, followed by infusion of 3-5 mg/h 6
- While primarily used for β-blocker overdose, it can help mobilize glucose in insulin overdose
- Octreotide: Consider in non-diabetic patients to prevent rebound hypoglycemia from endogenous insulin release 8
- Typical dose is 50-100 mcg subcutaneously or IV every 6-12 hours
- Surgical excision: Can be considered if the injection site is identifiable, even days after overdose 3
Duration of Monitoring and Treatment
- Prepare for extended hospitalization with median duration of 94 hours (range 12-721 hours) for insulin overdoses 4
- For ultra-long-acting insulins like icodec, monitoring may be required for up to 7 days or longer 2, 3
- Do not discontinue glucose infusions prematurely, as recurrent hypoglycemia is common even after apparent clinical recovery 1
- One-third of insulin overdose cases require intensive care unit admission 4
Special Considerations for Insulin Icodec
- As a 7-day acting insulin, icodec will have significantly prolonged effects compared to traditional long-acting insulins 2
- The risk of recurrent hypoglycemia is extremely high, requiring vigilant monitoring even after initial stabilization 1
- Consult with a medical toxicologist or poison control center for guidance on this specific formulation 6