Sulfonylurea Ingestion-Author's Reply

Abstract

Ms. Quadrani’s Reply: We appreciate Dr. Robertson’s lucid comments. The issue of management of the normoglycemic child with a normal examination after a history of a sulfonylurea ingestion (the most common presentation) is one with wide disagreement. This may be in a large part because of lack of data in this area. Dr. Robertson’s argument that we are over treating these children is one end of the spectrum of disagreement. In an accompanying editorial to our article there was further agreement that management of these asymptomatic uses remains controversial. A follow up prospective study has been completed in an attempt to provide more data and address some of these management issues. Several issues raised by Dr. Robertson require specific response. First, the use of blood glucose measurements, and specifically 60 mg/dL, was overly conservative is one of judgement. We agree that children may transiently experience blood glucose well below 60 mg/dL without injury. The use of 60 mg/dL was not used as a marker of where injury occurred but as a separation line of those who were and were not showing the effects of the drug. In reviewing the charts for this study we found that clinicians routinely began interventions based on laboratory evidence rather than waiting for behavioral evidence such as lethargy, coma, or seizures. These interventions, primarily IV glucose, were aimed at averting arrival of these same behavioral effects. A second issue is whether blood glucose measurements are necessary and whether management should be based on clinical behavior. We eagerly await report in a peer review setting of Dr. Robertson’s findings before any judgement on this issue. However, in the absence of studies M data to clarify the issue, most clinicians will continue to manage these cases relying heavily on laboratory evidence of hypoglycemia. Dr. Robertson’s main assertion that the pendulum has swung too far toward the conservative side may be valid. Seventy percent of all pediatric sulfonylurea ingestions reported to poison centers have outcomes of no effect? while greater than 90% of these exposures are managed in a hospital setting, incurring great expense and some risk as Dr. Robertson suggests. In a follow-up prospective study, a number of these issues have begun to be addressed.2 As we stated in our article, we invite further study of this important area.