What is the treatment for a suspected glimepiride (a sulfonylurea oral hypoglycemic agent) poisoning in an adult or geriatric patient with a history of type 2 diabetes?

Management of Glimepiride Poisoning

Treat glimepiride poisoning with immediate oral glucose for mild hypoglycemia, or glucagon/intravenous dextrose for severe cases, followed by prolonged observation with continuous glucose monitoring and repeated dextrose administration for at least 24-48 hours due to glimepiride's long duration of action. 1

Immediate Treatment Based on Severity

Mild Hypoglycemia (Conscious, Able to Swallow)

• Administer 15-20 grams of oral glucose (glucose tablets, juice, or regular soda) immediately 1
• Recheck blood glucose every 15 minutes and repeat treatment until glucose normalizes 1
• Do not discharge the patient after initial recovery—glimepiride's prolonged action means hypoglycemia will recur 1

Severe Hypoglycemia (Coma, Seizure, Neurological Impairment)

• Administer glucagon 1 mg intramuscularly or subcutaneously, OR intravenous dextrose (25-50 grams as D50W bolus) 1
• Glucagon may be less effective if glycogen stores are depleted (elderly, malnourished, chronic alcohol use), making IV dextrose the preferred option in these populations 1
• Establish continuous IV access immediately and prepare for prolonged dextrose infusion 1

Critical Management Principle: Prolonged Observation

The most dangerous pitfall in sulfonylurea poisoning is premature discharge after apparent clinical recovery. Glimepiride has a half-life that allows once-daily dosing, meaning its hypoglycemic effects persist for 24+ hours 2, 3.

• Admit all patients with glimepiride overdose for continuous glucose monitoring for at least 24-48 hours 1
• Hypoglycemia frequently recurs after initial correction, even when the patient appears clinically recovered 1
• Establish continuous IV dextrose infusion (D10W at 75-125 mL/hour) to maintain blood glucose 100-150 mg/dL 1

Monitoring Protocol

• Check blood glucose every 1-2 hours initially, then every 2-4 hours once stable 1
• Monitor for neurological symptoms: confusion, altered mental status, seizures 1
• In elderly patients or those with renal impairment, extend observation to 48-72 hours due to prolonged drug clearance 4, 5
• Continue frequent carbohydrate intake even after IV dextrose is discontinued 1

Special Considerations in High-Risk Populations

Elderly Patients

• Glimepiride carries lower hypoglycemia risk than glyburide or chlorpropamide, but elderly patients remain at substantially elevated risk due to impaired counter-regulatory responses 4, 5
• Prolonged observation (48-72 hours) is mandatory in patients over 65 years 4
• These patients may have impaired hypoglycemia awareness, making clinical monitoring unreliable 4

Renal Impairment

• Although glimepiride lacks active metabolites that accumulate in renal failure (unlike glyburide), clearance is still reduced in chronic kidney disease 5, 6
• Extend monitoring period to 48-72 hours in patients with eGFR <60 mL/min/1.73 m² 5, 6

Intentional Overdose

• Consider psychiatric evaluation before discharge 1
• Ensure no access to additional sulfonylurea medications 1

Common Pitfalls to Avoid

• Never discharge after a single normal glucose reading—recurrent hypoglycemia is the rule, not the exception 1
• Do not rely on oral glucose alone in moderate-to-severe cases—establish IV access early 1
• Do not assume glucagon will work in malnourished or chronic alcohol users—use IV dextrose as first-line 1
• Do not stop monitoring at 12 hours—glimepiride's effects persist well beyond this timeframe 2, 3

Disposition

• Admit all patients to a monitored setting (ICU for severe cases, telemetry/step-down for moderate cases) 1
• Discharge only after 24-48 hours of stable normoglycemia without IV dextrose support 1
• Provide clear instructions about hypoglycemia symptoms and emergency glucose administration 1
• Arrange urgent endocrinology or primary care follow-up within 48-72 hours of discharge 4