What is the antidote for sulfonylurea overdose?

Antidote for Sulfonylurea (Gliclazide/Dimicrone) Overdose

Glucagon is the antidote for sulfonylurea-induced hypoglycemia, administered at 1 mg subcutaneously, intramuscularly, or intravenously for adults and patients weighing ≥20 kg, with a repeat dose after 15 minutes if no response occurs. 1

Immediate Management Algorithm

Step 1: Recognize Severe Hypoglycemia

• Sulfonylureas like gliclazide (dimicrone) cause hypoglycemia by stimulating insulin release from pancreatic β-cells 2, 3
• Severe hypoglycemia requires assistance from others to recover and may lead to permanent neurological damage or death 4
• Long-acting sulfonylureas pose particular risk for prolonged, life-threatening hypoglycemia 5, 4

Step 2: Administer Glucagon Immediately

For adults and patients ≥20 kg:

• Administer 1 mg (1 mL) glucagon subcutaneously or intramuscularly into upper arm, thigh, or buttocks 1
• Healthcare providers may alternatively administer intravenously 1
• If no response after 15 minutes, give an additional 1 mg dose while waiting for emergency assistance 1

For pediatric patients <20 kg:

• Administer 0.5 mg (0.5 mL) or 20-30 mcg/kg subcutaneously or intramuscularly 1
• If no response after 15 minutes, give an additional 0.5 mg dose 1

Step 3: Call Emergency Services

• Call for emergency assistance immediately after administering glucagon 1
• Sulfonylurea-induced hypoglycemia can be prolonged and recurrent, requiring hospital monitoring 4, 6

Step 4: Provide Oral Carbohydrates

• When the patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence 1
• This is critical because sulfonylurea effects persist beyond the initial hypoglycemic episode 5

Critical Clinical Considerations

Why Sulfonylurea Hypoglycemia Is Particularly Dangerous

• Prolonged duration: Unlike insulin-induced hypoglycemia, sulfonylurea hypoglycemia can last 24-72 hours due to continued pancreatic insulin secretion 5, 4
• Recurrence risk: Even after initial correction, hypoglycemia frequently recurs as the drug continues to stimulate insulin release 6, 3
• Higher risk populations: Elderly patients, those with renal impairment, irregular eating patterns, or on interacting medications (fluoroquinolones, trimethoprim-sulfamethoxazole) face substantially elevated risk 5, 7

Hospital Admission Criteria

All patients with sulfonylurea-induced hypoglycemia requiring glucagon should be hospitalized for:

• Continuous glucose monitoring for at least 24 hours 4
• Repeated dextrose administration as needed 6
• Observation for recurrent hypoglycemia 5

Common Pitfalls to Avoid

• Do not discharge after single glucose correction: Sulfonylurea effects persist, causing recurrent hypoglycemia hours later 4, 6
• Do not rely on oral glucose alone: Glucagon is essential for severe cases where the patient cannot safely swallow 1
• Do not underestimate long-acting agents: Chlorpropamide and glyburide cause more prolonged hypoglycemia than shorter-acting agents like glipizide 5, 6

Additional Supportive Measures

In-Hospital Management

• Intravenous dextrose infusion (D10W or D5W) to maintain euglycemia 4
• Frequent glucose monitoring (every 1-2 hours initially) 5
• Consider octreotide 50-100 mcg subcutaneously every 6-12 hours in refractory cases to suppress insulin secretion (though this is off-label and based on case reports) 4

Prevention of Recurrence

• Discontinue or reduce sulfonylurea dose in elderly patients, those with renal impairment, or irregular eating patterns 5, 7
• Educate patients and caregivers on hypoglycemia recognition and glucagon administration 1
• Consider switching to agents with lower hypoglycemia risk (metformin, DPP-4 inhibitors, GLP-1 agonists, SGLT2 inhibitors) 2, 5