Glucose elevating agents

Generic and Brand Names

• Dextrose (glucose) IV — D50W, D25W, D10W (hospital generics)

• Oral glucose — Glucose gel/tablets (various generics)

• Glucagon (rDNA), IM/SC/IV — GlucaGen HypoKit, Gvoke (pre-filled syringe/auto-injector)

• Glucagon (intranasal) — Baqsimi

• Dasiglucagon (SC) — Zegalogue

• Diazoxide (oral) — Proglycem

• Octreotide (SC/IV) — Sandostatin (adjunct in sulfonylurea-induced hypoglycemia)

Class

• Antihypoglycemic “glucose elevating” agents used for rapid correction of clinically significant hypoglycemia and for conditions of inappropriate insulin excess.

• Core subgroups: exogenous glucose (IV/PO), glucagon receptor agonists (parenteral and intranasal), insulin-secretion inhibitors (diazoxide), and somatostatin analogs (octreotide, adjunct).

Mechanism of Action

• Dextrose (IV) / Oral glucose: Directly supplies circulating glucose.

• Glucagon / Dasiglucagon: Activate hepatic glucagon receptors → ↑ glycogenolysis and gluconeogenesis; transient AV nodal effects possible.

• Diazoxide: Opens β-cell K_ATP channels → inhibits insulin release → raises plasma glucose.

• Octreotide (adjunct): Somatostatin analogue → inhibits insulin secretion; limits recurrent hypoglycemia in sulfonylurea toxicity.

Indications

• Treatment of severe hypoglycemia (patient unable to self-treat or unconscious).

• Pre-hospital and community rescue: glucagon (IM/SC), intranasal glucagon, dasiglucagon devices.

• Hospital/ED: IV dextrose for rapid reversal; octreotide to prevent recurrent hypoglycemia after sulfonylureas; diazoxide for hyperinsulinemic hypoglycemia (e.g., congenital or adult islet cell disorders).

• Secondary labeled uses: glucagon for GI motility suppression during imaging/endoscopy (not a “glucose-elevating” purpose, but on label).

Dosage and Administration

• Dextrose IV (adults): 25 g as D50W 50 mL IV push; alternatives include D10W 100–250 mL titrated to response (prefer D10W to reduce extravasation injury).

• Dextrose IV (pediatrics): D10W 2–5 mL/kg (avoid D50W boluses in young children).

• Oral glucose gel/tablets (mild/moderate, able to swallow): 15–20 g; recheck glucose in 15 min; repeat if needed.

• Glucagon IM/SC: Adults/adolescents 1 mg; children <25 kg or <6–8 years 0.5 mg.

• Glucagon IV: 1 mg IV if access available (less commonly used than dextrose).

• Glucagon intranasal (Baqsimi): 3 mg spray into one nostril; may repeat with second device if no response after ~15 minutes.

• Dasiglucagon (Zegalogue) SC: 0.6 mg single dose (pre-filled auto-injector or syringe); a second dose may be given after ~15 minutes if needed.

• Diazoxide (Proglycem) oral: Commonly 3–8 mg/kg/day in divided doses; titrate to glycemic response (specialist oversight; chronic use).

• Octreotide (sulfonylurea overdose): 50–100 mcg SC every 6–12 h or 50 mcg IV bolus then 25–50 mcg/h IV infusion, titrated to prevent recurrent hypoglycemia.

Monitoring

• Capillary/venous glucose every 15 minutes until stable, then spaced out.

• Potassium and other electrolytes with repeated IV dextrose; volume status in frail/renal patients.

• Rebound hypoglycemia risk post-glucagon if hepatic glycogen depleted; ensure oral/enteral carbohydrate once awake.

• Diazoxide: BP, edema/weight, uric acid, CBC; watch for fluid retention and heart failure.

• Octreotide: Glucose (for hypo-/hyperglycemia), GI symptoms, heart rate; consider gallbladder ultrasound with prolonged use.

Contraindications

• Glucagon/Dasiglucagon: Pheochromocytoma (risk hypertensive crisis), insulinoma (rebound hypoglycemia), hypersensitivity.

• Diazoxide: Hypersensitivity (thiazide-related structure), functional hypoglycemia not due to hyperinsulinism, decompensated HF (relative).

• Dextrose IV: Hyperosmolar injury risk with D50W; caution in intracranial pathology where acute hyperglycemia is undesirable.

• Octreotide: Hypersensitivity; caution in bradyarrhythmias and gallbladder disease.

Precautions

• Airway protection: Post-glucagon emesis risk—place patient in lateral position.

• Hepatic glycogen: Poor response to glucagon in prolonged fasting, alcohol-related hypoglycemia, adrenal insufficiency—use IV dextrose.

• Device training: Caregivers should practice with trainers for Baqsimi, Gvoke, Zegalogue.

• Pediatrics/neonates: Avoid hyperosmolar dextrose boluses; use D10W with careful titration.

• Diazoxide: Edema, hypertrichosis, hyperuricemia; may worsen CHF; use diuretics if needed under specialist care.

• Octreotide: May cause transient hyperglycemia; monitor and adjust insulin/orals.

Adverse Effects

• Dextrose IV: Phlebitis, extravasation necrosis (D50W), hyperglycemia, fluid shifts.

• Glucagon/Dasiglucagon: Nausea/vomiting, headache, tachycardia, hypertension; nasal irritation with Baqsimi.

• Diazoxide: Edema/fluid retention, hypotension, hypertrichosis, hyperuricemia, GI upset; rare hematologic effects.

• Octreotide: Abdominal cramps, diarrhea, nausea, bradycardia, gallstones with longer use.

Drug Interactions

• Glucagon: Antagonized by indomethacin; may enhance warfarin anticoagulation; with beta-blockers can cause marked BP/HR changes.

• Diazoxide: Additive hypotension with antihypertensives; raises glucose—adjust antidiabetics; may increase uric acid with diuretics.

• Octreotide: Alters insulin/oral hypoglycemic needs; may reduce cyclosporine levels; additive bradycardia with beta-blockers.

Overdose

• Dextrose: Hyperglycemia/osmotic diuresis—treat supportively, consider insulin if severe.

• Glucagon/Dasiglucagon: N/V, hyperglycemia, transient BP/HR changes—supportive care.

• Diazoxide: Refractory hyperglycemia, hypotension, fluid overload—supportive care, diuretics, adjust dose.

• Octreotide: Bradycardia, GI upset—supportive care; rarely require atropine or dose reduction.

Patient Counselling

• Keep rescue kits with the patient and trained caregivers; check expiry dates.

• After responsiveness returns, eat long-acting carbohydrate to prevent recurrence.

• If no response after 10–15 minutes, use a second device (where indicated) and call emergency services.

• For nasal glucagon: no inhalation required; one spray into one nostril.

• Teach signs of hypoglycemia and the “15-15 rule” for mild episodes (15 g carb, recheck in 15 minutes).

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Comparison Table — Glucose Elevating Agents

Agent	Route	Typical Adult Dose	Onset	Key Use Case	Advantages	Important Cautions
Dextrose (IV)	IV (D10W/D25W/D50W)	25 g (D50W 50 mL) or titrated D10W	Minutes (immediate)	Hospital/ED severe hypoglycemia	Fastest correction; works even with depleted glycogen	Extravasation injury with D50W; transient hyperglycemia
Oral glucose	PO (gel/tablets)	15–20 g; repeat as needed	10–15 min	Mild–moderate hypoglycemia if able to swallow	Simple, widely available	Not for unconscious patients; aspiration risk if AMS
Glucagon (IM/SC)	IM/SC (kit or autoinjector)	1 mg (0.5 mg child <25 kg)	~5–15 min	Community/home rescue without IV access	Portable; caregiver-administered	N/V; poor efficacy if glycogen depleted; CI: pheochromocytoma/insulinoma
Glucagon (intranasal)	Intranasal	3 mg single spray	~10–15 min	Needle-free rescue	No injection; works through congestion	Nasal irritation; repeat needs second device
Dasiglucagon (SC)	SC autoinjector	0.6 mg	~7–10 min	Rescue similar to glucagon with stable formulation	Ready-to-use, stable; consistent response	Same CIs as glucagon; N/V, headache
Diazoxide (oral)	PO (chronic)	3–8 mg/kg/day divided	Days (titrated)	Hyperinsulinemic hypoglycemia (congenital/acquired)	Treats underlying insulin excess	Edema, hypotension, hypertrichosis; monitor closely
Octreotide (SC/IV)	SC/IV	50–100 mcg SC q6–12h or IV infusion	Minutes–hours	Prevent recurrent hypoglycemia in sulfonylurea overdose	Reduces insulin secretion; prevents rebound	GI effects, bradycardia, gallstones (longer use)