Practice 10-Minute Consultation


BMJ 2011; 342 doi: (Published 16 February 2011) Cite this as: BMJ 2011;342:d567

Avoid 50% Dextrose!

Re: Practice:
Piya Sen Gupta, Andrea N Green, and Tahseen A Chowdhury
BMJ 2011 342:d567; doi:10.1136/bmj.d567

The authors are to be congratulated for producing a concise review of
an important area of clinical management bridging primary and secondary
care services in the UK. However there are 3 areas that are worthy of
further comment:

1) Figure 1 suggests the use of intravenous 50% dextrose for the emergency
rescue of the unconscious patient with hypoglycaemia in the community.
Most UK hospitals guidelines now suggest avoiding anything more
concentrated than 20% dextrose. The main concern is that 50% dextrose is
caustic to tissues if it extravasates out of the vascular space, a
significant risk where cannulation is attempted out of hospital.

2) Whipple's triad is not necessarily a useful diagnostic for insulin
induced hypoglycaemia in diabetes. As partly alluded to in the review, two
of Whipple's three criteria- the presence of symptoms which are then
reversed following administration of glucose- may be absent in patients
who have lost warning symptoms of hypoglycaemia. In clinical practice, the
greater problem is arguably not so much the diagnosis of hypoglycaemia in
this situation but rather the recognition that it is problematic by
patients and/or health care providers.

3) Finally, although at face value the use of the long acting insulin
analogue, glargine, contradicts current NICE guidelines, type 2 diabetes
is a heterogeneous condition and there is an increasing realisation that
many slim, insulin-sensitive patients like this requiring exogenous
insulin therapy may actually have a "slow burning" type 1 diabetes (which
has attracted various monikers over the years including "type 1.5
diabetes"). There is a high likelihood that the patient presented here may
progress to requiring a full "basal-bolus" regimen including insulin
analogue therapy where appropriate to achieve decent glycaemic control
without hypoglycaemia, probably requiring specialist referral, something
that primary care practitioners should be aware of.

Competing interests: No competing interests

21 February 2011
Mark L Evans
University Lecturer/ Honorary Consultant Physician
Institute of Metabolic Science, University of Cambridge