Comparison of Octreotide and Standard Therapy Versus Standard Therapy Alone for the Treatment of Sulfonylurea-Induced Hypoglycemia

Abstract

We read with interest the recent study detailing the use of octreotide for sulfonylurea-induced hypoglycemia.1Fasano C.J. O'Malley G. Dominici P. et al.Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia.Ann Emerg Med. 2008; 51: 400-406Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar While we commend the authors for performing a much needed randomized controlled trial, we have several concerns regarding the study design and implementation. Although the investigators attempted to control for oral glucose intake, they were unable to do so either in the emergency department or on the inpatient floor. Seventy five percent of participants were unwilling to ingest the oral carbohydrates provided in the study protocol and preferred a standard food tray. It is possible that this difference could have altered the study results. Additionally, the study included patients who were on combined insulin and oral sulfonylurea therapies. While octreotide is thought to be of benefit in the setting of insulin-secreting agents such as sulfonylureas, it is not expected to alter the effects of exogenous insulin. Reporting the allocation of study participants with mixed hypoglycemic medication treatments may have illuminated this potential confounding variable. Finally, the authors report patients with recurrent hypoglycemia at times greater than 8 hours post ingestion as treatment failures. While we appreciate their forthrightness, we feel that they have unfairly biased the results. As noted in the paper, the dose of octreotide is not known. However, its duration of action is not expected to be longer than 6 to 8 hours. Controlling for this would support the authors' statement that octreotide prevents recurrent hypoglycemia. In conclusion, this study would have been strengthened by greater control of glucose intake and more detail about the possible confounding effects of insulin. While the definitive dose of octreotide and the administration interval for repeat use has not been satisfactorily prospectively validated, we would contend that 50 micrograms administered subcutaneously every 6 hours has both pharmacokinetic and theoretic support.2Howland MA. Antidotes in depth. Octreotide. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. Calgary, Alberta, Canada: McGraw-Hill; 611-613.Google Scholar Use of repeat dosing would most likely have given greater support to the conclusion. Comparison of Octreotide and Standard Therapy Versus Standard Therapy Alone for the Treatment of Sulfonylurea-Induced HypoglycemiaAnnals of Emergency MedicineVol. 51Issue 4PreviewThis study is designed to test the hypothesis that the administration of octreotide acetate (Sandostatin; Novartis Pharmaceuticals) in addition to standard therapy will increase serum glucose level measured at serial intervals in patients presenting to the emergency department (ED) with sulfonylurea-induced hypoglycemia compared with standard therapy alone. Full-Text PDF In replyAnnals of Emergency MedicineVol. 51Issue 6PreviewWe appreciate Dr. Francis' interest in our study and we would like to respond to his comments. Dr. Francis and his coauthors make several suggestions, most of which have already been recognized and acknowledged in the limitations and discussion sections of the manuscript. Full-Text PDF