Drug-induced hypoglycemia. A review of 1418 cases.

The present review catalogues 1418 reported cases of drug-induced hypoglycemia. The main findings are that sulfonylureas (especially chlorpropamide and glyburide), either alone or with a second hypoglycemic or potentiating agent, still account for 63% of all cases; that alcohol, propranolol, and salicylate, either singly or with another hypoglycemic drug, are the next most frequent offenders (19% of the total); and that one older drug (quinine) and three new ones (pentamidine, ritodrine, and disopyramide) have caused an additional 7% of all episodes of severe hypoglycemia. The clinical factors that set the stage for drug-induced hypoglycemia are still restricted food intake, age, hepatic disease, and renal disease, both individually and even more so in combination. Drug-induced hypoglycemia continues to be so common that virtually every unconscious patient should be considered hypoglycemic until immediate estimation of the blood sugar level rules it in or out. If ruled in, the clinician should promptly start 10% intravenous glucose and plan to maintain it uninterruptedly for 1 or more days, with added glucagon, hydrocortisone, and diazoxide administration if necessary, until sustained hyperglycemia guarantees that all drug effects have worn off.

Are insulin receptors clinically significant?

Everything we know today about the functional defects underlying clinical diabetes mellitus was known before insulin receptors came along. Growth-onset (type I) diabetes stems from primary beta-cell failure; in these patients insulin sensitivity is normal, and the number of insulin receptors on target cells is normal. Adult-onset (type II) diabetes represents a combination of relative insulin deficiency (impaired early response to glycemic stimulus with subsequent hyperinsulinemia, at first) and peripheral insulin resistance, both of which engender 24 hr hyperinsulinemia that secondarily reduces insulin receptor concentrations. Concomitant obesity increases circulating hyperinsulinemia in moderately severe diabetes; however, excessive insulin levels wane as diabetes gets worse, and round-the-clock hypoinsulinemia supervenes. We still have to learn what fails to happen beyond the receptor concerning both glucose transport into the cell and insulin-mediated intracellular processes, but these postreceptor defects are undoubtedly related to deficient insulin secretion. In short, the hormone is more important than the receptor.

Uniphasic insulin-secretory response in the pancreatic vein of dogs after an enteric glucose load.

The insulin secretory response to an enteric glucose load was measured in 11 dogs after intrajejunal instillation of a 25 per cent glucose solution (1.75 gm./kg.) in five minutes. Insulin outflow rate was measured every minute for 10 minutes, then at increasing intervals through 60 minutes. Starting at two minutes after onset of glucose loading, mean arterial plasma glucose rose steadily throughout the hour. This was paralleled by a similarly progressive rise in mean pancreatic venous plasma insulin output starting at seven minutes and peaking at 50 minutes, despite partial masking by a simultaneous fall in pancreatic venous plasma flow rate after the fourth minute. The data indicate that the normal insulin response to an enterically administered glucose stimulus is a smoothly rising uniphasic one, in contrast to the typical biphasic insulin response to a "square-wave" intravenous glucose stimulus.

Influence of antecedent carbohydrate intake on the biphasic insulin response to intravenous glucose.

The insulin secretory response to a sudden and sustained intravenous glycemic stimulus was measured in three groups of dogs whose antecedent carbohydrate intake ranged from zero to 300 or more grams daily. Insulin outflow rate from the pancreaticoduodenal vein was measured every minute for ten minutes, then at increasing intervals through sixty minutes. It was found that starvation erased the first phase of the biphasic insulin response shown by dogs on ordinary carbohydrate intake and that high-carbohydrate intake abolished the trough between the two phases. The data suggest that, during truly physiologic stimulation of insulin secretion, the latter represents the final stage of a continuum of hormonal synthesis, storage, and release, rather than emanating from one of two separate pools of fast-versus-slow insulin secretion.

Confirmation of impaired early insulin response to glycemic stimulus in nonobese mild diabetics.

The initial insulin responses of nonobese normal subjects and mild diabetics were analyzed during and after five-minute and two-minute infusions of 0.5 gm. per kilogram of glucose by vein. It was found that the two-minute injection elicited faster and significantly higher absolute hormonal output in both normals and diabetics, and that on both tests the normal subjects secreted significantly more insulin than did the mild diabetics. Comparison of respective "insulinogenic indexes" (net insulin output per unit of glycemic stimulus) showed that the corrected early insulin responses were in fact the same on both the five-minute and two-minute tests in normal subjects, and also in mild diabetics; but that the corrected insulin output was still twice as great in control subjects on both tests. It was also found that obese mild diabetics had significantly greater absolute insulin responses to both the five-minute and two-minute glucose injections than did their nonobese counterparts. These findings reconfirm that the earliest clinically recognizable state of diabetes mellitus is characterized by an impaired initial insulin secretory response to glycemic stimulus. They also indicate that valid interpretations of the influence of mild diabetes per se on the early insulin response can only be drawn from data obtained in nonobese individuals. Diabetes 24:17-24, January, 1975.