What is the recommended hourly dose of D10 (10% dextrose solution) for an 80 kg man with hypoglycemia due to suspected sulfonylurea toxicity?

D10 Infusion Rate for Sulfonylurea-Induced Hypoglycemia

For an 80 kg man with suspected sulfonylurea toxicity, start D10 at 50 mL/hour (5 grams of dextrose per hour) as the initial continuous infusion rate. 1

Initial Management Algorithm

Acute Hypoglycemia Correction First

Before starting continuous D10, you must first correct the acute hypoglycemia:

• Administer 10-20 grams of D50 intravenously as initial bolus therapy, titrated based on the severity of hypoglycemia 2
• Give in 5-10 gram aliquots every 1-2 minutes rather than a single large bolus to avoid overcorrection 3
• Recheck blood glucose at 15 minutes and repeat dextrose as needed until blood glucose exceeds 70 mg/dL 2
• Rapid administration of full 25-gram D50 boluses has been associated with cardiac arrest and hyperkalemia 1, 2

Transition to Continuous D10 Infusion

Once acute hypoglycemia is corrected:

• Start D10 at 50 mL/hour (5 grams/hour) as the standard initial rate 1
• This rate aligns with physiologic glucose utilization and provides basal glucose coverage 1
• The 5 grams/hour rate prevents recurrent hypoglycemia while avoiding hyperglycemia 1

Critical Monitoring Requirements

Blood glucose monitoring is essential:

• Check blood glucose every 1-2 hours during the continuous infusion 1, 2
• Additional checks at 15 minutes and 60 minutes after any dextrose bolus administration 3, 2
• More frequent monitoring (every 15 minutes) may be needed during initial titration 1

Sulfonylurea-Specific Considerations

Why Sulfonylurea Toxicity is Different

Sulfonylurea-induced hypoglycemia is particularly challenging because:

• Hypoglycemia can be delayed (1.5-16 hours post-ingestion) and profoundly sustained 4
• Continuous dextrose infusions alone are often insufficient to maintain euglycemia 5, 6
• Recurrent hypoglycemia occurs in 22-50% of patients despite aggressive dextrose therapy 4

Octreotide as First-Line Adjunctive Therapy

Octreotide should be strongly considered as first-line therapy alongside dextrose for sulfonylurea toxicity:

• Administer octreotide 50 mcg subcutaneously or IV, followed by three additional 50 mcg doses every 6 hours 4
• Octreotide inhibits insulin secretion from pancreatic beta-cells, addressing the root cause of sulfonylurea toxicity 4
• It significantly reduces dextrose requirements and prevents recurrent hypoglycemic events compared to dextrose alone 4
• Studies demonstrate prompt and sustained resolution of hypoglycemia with octreotide when continuous dextrose was contraindicated or ineffective 5, 6, 7

Adjusting the D10 Rate

Titrate the infusion based on blood glucose response:

• If blood glucose remains <70 mg/dL despite 50 mL/hour, increase the rate incrementally while monitoring closely 2
• If blood glucose rises >180 mg/dL, reduce the infusion rate to avoid iatrogenic hyperglycemia 3
• Target post-treatment glucose of 100-180 mg/dL rather than aggressive normalization 3

Common Pitfalls to Avoid

• Do not rely solely on intermittent D50 boluses in sulfonylurea toxicity—this leads to a cycle of hypoglycemia and rebound hyperglycemia 5, 6
• Do not delay octreotide administration if hypoglycemia recurs despite adequate dextrose infusion 4, 8
• Do not use hypotonic solutions (5% dextrose alone) for acute correction—these are insufficient for rapid treatment 2
• Do not stop monitoring prematurely—sulfonylurea effects can persist for 12+ hours after apparent resolution 8

Duration of Therapy

• Continue D10 infusion and monitoring for at least 12 hours after discontinuation of all dextrose boluses and octreotide 8
• Observation periods may need to be longer depending on the specific sulfonylurea involved and formulation (extended-release products require longer monitoring) 8
• Gradually taper the D10 infusion rather than abrupt discontinuation to prevent rebound hypoglycemia 1