What is the immediate treatment for a 10x insulin overdose to prevent severe hypoglycemia?

Immediate Management of 10x Insulin Overdose

Stop the insulin infusion immediately and administer 10-20 grams of IV dextrose (50% solution) as a bolus, then initiate continuous IV glucose infusion with frequent blood glucose monitoring every 15 minutes initially. 1, 2

First-Line Actions (Within Minutes)

• Stop all insulin administration immediately - this is the absolute first step 1
• Administer 10-20 grams of hypertonic (50%) dextrose IV - titrate the dose based on the severity of hypoglycemia to avoid overcorrection 1
• Check blood glucose immediately before treatment if possible, but do not delay treatment if testing is unavailable 3
• Recheck blood glucose in 15 minutes and repeat dextrose bolus if glucose remains <70 mg/dL 1, 2
• Initiate continuous 10% dextrose infusion to maintain euglycemia, as a single bolus will be insufficient for a massive overdose 1, 4

Critical Monitoring Requirements

• Monitor blood glucose every 15 minutes initially, then hourly once stabilized 1, 2
• Monitor serum potassium closely - insulin overdose causes profound hypokalemia in 49% of cases due to intracellular potassium shift 5
• Check other electrolytes (magnesium, phosphate) as disturbances occur in 42% of insulin overdose cases 5
• Monitor hepatic function - acute hepatic injury occurs in 7% of cases 5
• Cardiac monitoring is essential as cardiac arrhythmias occur in 9% of overdose cases 5

Anticipate Prolonged Course

• Expect 48-96 hours of glucose requirements with long-acting insulin analogs (glargine, detemir, degludec) 6, 4
• Plan for hospitalization of 94 hours median duration (range 12-721 hours) based on systematic review of insulin overdose cases 5
• One-third of cases require ICU admission for intensive monitoring and management 5
• Do not discontinue glucose infusion prematurely - the duration of effect far exceeds the usual pharmacokinetic profile in overdose situations 6

Advanced Treatment Options

Glucagon Administration

• Consider continuous IV glucagon infusion if dextrose requirements become excessive or central access is unavailable 7
• Dose: 3-10 mg IV bolus over 3-5 minutes, followed by 3-5 mg/hour infusion 1
• Particularly useful in type 1 diabetes patients where concerns about precipitating endogenous insulin release do not apply 7
• Manage nausea with antiemetics as glucagon commonly causes vomiting 1
• Protect airway before administration if patient has altered mental status 1

Octreotide for Refractory Cases

• Consider octreotide if experiencing rebound hypoglycemia from dextrose-induced endogenous insulin release in non-diabetic patients 8
• Octreotide prevents dextrose-induced hypoglycemia by suppressing endogenous insulin secretion 8
• Initiate 12-24 hours post-overdose if glucose remains unstable despite high dextrose infusion rates 8

Concentrated Dextrose Solutions

• Use 20% dextrose infusion if 10% dextrose volumes become excessive and cause fluid overload 4
• Peripheral edema is a common complication from large dextrose infusion volumes 8
• Central venous access may be required for concentrated dextrose solutions >10% 1

Neurological Complications

• Intermittent cerebral impairment occurs in 73% of cases including confusion, seizures, and loss of consciousness 5
• Permanent hypoglycemic encephalopathy is possible with severe or prolonged glycopenia 1
• One death reported in systematic review of 45 insulin overdose cases 5
• Maintain glucose >70 mg/dL (>100 mg/dL if neurologic injury present) to prevent neurocognitive damage 1

Common Pitfalls to Avoid

• Do not underdose initial dextrose - use the full 10-20 grams based on severity 1
• Do not stop glucose infusion when patient appears stable - effects are extremely prolonged 6, 4
• Do not forget to replace potassium - hypokalemia is nearly universal and can cause cardiac arrhythmias 5
• Do not target aggressive potassium repletion >2.8 mEq/L in the acute phase to avoid asystole 1
• Do not overlook the need for oral carbohydrates once patient is conscious and able to swallow 9, 10

Disposition and Follow-up

• Admit all patients with 10x insulin overdose for extended monitoring 5
• Expect median hospitalization of 4 days but prepare for up to 30 days in severe cases 5
• Provide psychiatric evaluation for intentional overdoses before discharge 5
• Restart diabetes medications cautiously in diabetic patients after overdose effects resolve 4