Sulfonylurea (Glipizide/Glyburide) ịweụbiga mmanya ókè: Gịnị kpatara shuga ọbara ji agbaji ugboro ugboro mgbe Glucose gasịrị.¶

** Sulfonylureas *** - gụnyere ** glipizide (Glucotrol, Glucotrol XL), ** glyburide / glibenclamide (DiaBeta, Glynase, Micronase), glimepiride (Amaryl), gliclazide (Diamicron), gliclazide (Diamicron), na ** chlorpropamide dị ka ihe na-eme ngwa ngwa. (repaglinide [Prandin] na nateglinide [Starlix]) bụ ọgwụ ọnụ Ụdị ọrịa shuga 2 nke a na-akpọ insulin secretagogues. N'adịghị ka ** metformin *** (nke na-arụ ọrụ site na imeziwanye uche insulin na ọ fọrọ nke nta ka ọ ghara ibelata shuga ọbara n'okpuru nkịtị na onye ahụ dị mma), sulfonylureas na-ejikọ ozugbo na ** Sulfonylurea Receptor-1.SUR1) nke ATP-sensitive potassium (K-ATP) Ọwa *** na mkpụrụ ndụ beta nke pancreatic, na-amanye pancreas ka ọ tụba nnukwu ebili mmiri na-aga n'ihu nke endogenous *insulin ** n'ime ọbara n'agbanyeghị etu shuga ọbara onye ọrịa na-agbada. N'ihi ya, ** sulfonylureas nọ na ndepụta ụmụaka "Otu pill nwere ike igbu" : otu. 5 mg ma ọ bụ 10 mg mbadamba glipizide ma ọ bụ glyburide na mberede nwata loro - ma ọ bụ usoro ọgwụgwọ kwa ụbọchị nke na-agbakọ na okenye toro eto n'ihi nnukwu mmerụ ahụ akụrụ ma ọ bụ mmekọrịta ọgwụ (dị ka ** trimethoprim-sulfamethoxazole [Bactrim] ma ọ bụ ** fluconazole) - na-akpata ** nnukwu, ogologo oge, na-eyi ndụ egwu, na-emebi ụbụrụ na-adịgide adịgide na neuroglycopenia 4. 72+ awa *. Nke ka njọ, na-emeso ịdoụbiga mmanya ókè nke sulfonylurea dị ka mmeghachi omume insulin nkịtị site n'ịgbanye boluses ugboro ugboro ** Dextrose iravenous.D50W ma ọ bụ D25WNaanị ya na-akpalite ọnyà hypoglycemia na-alaghachi azụ ***: mmụba ọ bụla nke glucose IV na-akpali sulfonylurea-primed pancreas ịhapụ ihe ** ọbụlagodi nnukwu mmụba nke sulin, na-eme ka shuga ọbara daa laghachi azụ n'ọkwa na-egbu egbu.< 30 mg/dL ma ọ bụ < 1.7 mmol/L 30 ruo 60 nkeji ka emechara *** belụsọ ma ndị dọkịta na-enye ọgwụ mgbochi ọgwụ ozugbo, ** Octreotide (Sandostatin)**, iji mechie mwepụta insulin nke pancreatic na isi mmalite.

Ọ bụrụ na nwatakịrị loro ọbụna otu mkpụrụ ọgwụ ọrịa shuga, ma ọ bụ ọ bụrụ na okenye na-ewere glipizide, glyburide, glimepiride, ma ọ bụ gliclazide na-enwe mgbagwoju anya, ọsụsọ na-agba, na-ama jijiji, na-alụ ọgụ, na-ada ụda n'okwu ọnụ, ma ọ bụ na-anabataghị, kpọọ nọmba mberede mpaghara gị (911 na United States na Canada, 112 gafee European Union, United Kingdom 99). nọmba mberede ndekọ ozugbo, na nyochaa mberede ọrịa shuga, Ọrịa mamịrị ketoacidosis na ọnọdụ hyperosmolar, na enyemaka mbụ ọdịdọ.

Mee nke a ugbu a¶

1. ** Kpọọ 911/112/999 na njikwa nsi ozugbo wee lelee glucose ọbara mkpịsị aka ma ọ bụrụ na ị nwere mita : Ọ bụrụ na onye ọrịa ahụ na-arahụ ụra, mgbagwoju anya, okwu nkwutọ, ijide, ma ọ bụ na-anabataghị, kpọọ maka ụgbọ ihe mberede Advanced Life Support (ALS) ozugbo. Ọ bụrụ na nwatakịrị ma ọ bụ nwatakịrị nwere ike iloro ** ọbụlagodi otu sulfonylurea ma ọ bụ meglitinide pill (glipizide, glyburide/glibenclamide, glimepiride, gliclazide, repaglinide, buru ha gaa na ngalaba mberede ozugbo - ** ihe oriri sulfonylurea ụmụaka ọ bụla chọrọ nnabata ụlọ ọgwụ nke awa iri abụọ na anọ n'ihi na nnukwu hypoglycemia nwere ike ịda na mberede ** awa 8 ruo 18 mgbe ilochara ọgwụ ahụ *** (karịsịa mgbe nwatakịrị na-ehi ụra n'abalị).
2. ** Ọ bụrụ na onye ahụ na-eteta wee nwee ike ilo nke ọma, nye sugar na-eme ngwa ngwa PLUS nri nri carbohydrate/protein siri ike ozugbo**: Nye. 15 to 20 grams glucose na-arụ ọrụ ngwa ngwa (120 mL [4 oz] nke ihe ọṅụṅụ mkpụrụ osisi mgbe niile ma ọ bụ soda na-abụghị nri, mbadamba glucose 3 ruo 4, ma ọ bụ 1 tablespoon mmanụ aṅụ / shuga gbazere na mmiri), na-esote ozugbo nri carbohydrate na protein dị mgbagwoju anya (dị ka crackers butter butter ma ọ bụ cheese Sanwichi). ** etinyela nri, ihe ọ juiceụ ,ụ, ma ọ bụ jel n'ọnụ onye na-ehi ụra, na-ejide ya, ma ọ bụ onye amaghị ihe ọ bụla.**
3. ** Ghọta ihe kpatara ịgba ọgwụ GlucagonGlucaGen, Baqsimi, Gvoke) na-adakarị ma ọ bụ na-akawanye njọ nlọghachi azụ na nsi Sulfonylurea ***: Ọ bụrụ na onye ahụ amaghị ihe ọ bụla ma ọ nweghị IV dị ugbu a, ịnwere ike iji intramuscular ma ọ bụ intranasal mberede ** Glucagon kit ** ma ọ bụrụ na mmadụ nọ n'aka. Agbanyeghị, dọọ ndị na-ahụ maka ahụike aka na ntị na **glucagon dabere na ụlọ ahịa glycogen imeju (nke ike na-agwụ ngwa ngwa na ịdoụbiga mmanya ókè sulfonylurea) NA glucagon na-akpali ozugbo mkpụrụ ndụ beta nke pancreatic na-ezochikwu insulin, na-ebutekarị hypoglycemia nkwụghachi azụ n'ime nkeji 30 ruo 45.
4. ** Kpee ndị dọkịta na ndị na-ahụ maka ahụike mberede na "IV Dextrose Rebound Trap" wee rịọ OCTREOTIDE ***: Gwa ndị otu ahụike: "Nke a bụ Sulfonylurea (Glipizide / Glyburide / Glimepiride) ịdoụbiga mmanya ókè - D50W boluses ugboro ugboro ga-akpalite mweghachi insulin spikes; sugar."
5. **Amachibidola nri n'ime nwatakịrị asymptomatic na-echere n'ụlọ ọgwụ : Mgbe a na-anabata nwatakịrị maka nlele elekere 24 ka ọ loro ọgwụ sulfonylurea, ** ekwe ka nwatakịrị rie nri kwesịrị ekwesị mgbe ọ na-elele shuga ọbara n'akụkụ akwa akwa kwa awa 1 ruo 2. Agbanyeghị, ** ebidola dextrose intravenous prophylactic (D5W ma ọ bụ D10W) na-ata mmiri n'ime nwatakịrị asymptomatic nwere shuga ọbara nkịtị **, n'ihi na prophylactic IV glucose na-ezo ma nwatakịrị ahụ loro pill ahụ ruo mgbe agbanyụrụ mmiri ahụ wee ziga nwatakịrị ahụ n'ụlọ n'ihe mberede na-egbu egbu.
6. ** Lelee karama ọgwụ ndị ọzọ nke onye ọrịa maka "Zochie Sulfonylurea Multipliers" : Weta karama ọgwụ ọ bụla n'ụlọ ọgwụ. N'ime ndị toro eto nwere ọrịa shuga 2dị nke Abụọ, sulfonylurea coma na-eyi ndụ egwu na-ebutekarị ọ bụghị site n'ịṅụ ọgwụ ọzọ, kama site na ịmalite ọgwụ nje ma ọ bụ ọgwụ nje (Trimethoprim-Sulfamethoxazole [Bactrim/Septra], Fluconazole [Diflucan], Ciprofloxacin/Levofloxacin, ma ọ bụ akụrụ nke na-etolite, ma ọ bụ Clarithromy na-egbochi mkpochapụ nke arụ ọrụ ** glyburide ma ọ bụ ** glimepiride metabolites.

Osisi mkpebi: Ijikwa ọgwụ ụmụaka na okenye sulfonylurea / meglitinide ịdoụbiga mmanya ókè na Octreotide¶

flowchart TD
    Start["Sulfonylurea a na-enyo enyo (Glipizide, Glyburide/Glibenclamide, glimepiride, gliclazide) ma ọ bụ Meglitinide (Repaglinide, Nateglinide) ịdoụbiga mmanya ókè / mkpokọta."] --> CheckBG{"Lelee STAT Bedside Fingerstick & Lab Serum Glucose"}

    CheckBG -->|Hypoglycemic: Blood Glucose < 60-70 mg/dL (< 3.3-3.9 mmol/L) OR Any Neuroglycopenic Symptoms (Confusion, Diaphoresis, Seizures, Coma)| TreatHypo["1. Immediate Glucose Restoration: - Awake/Alert: Oral Glucose (15-20 g) + Complex Carbohydrate Meal - Altered/Unconscious: IV Dextrose Bolus (Adults: D50W 50 mL [25 g]; Children: D25W 2-4 mL/kg OR D10W 5-10 mL/kg [0.5-1 g/kg]) 2. Administer Activated Charcoal (1 g/kg) if < 1-2 Hours Post-Ingestion (Or up to 4-6h for Extended-Release Glipizide XL)"]

    CheckBG -->|Euglycemic & Asymptomatic: Blood Glucose >= 70 mg/dL (>= 3.9 mmol/L)| ObserveProtocol["1. Unyi na-arụ ọrụ (1 g / kg) ma ọ bụrụ na <1-2 Hours Post-ingestion 2. Kwe ka Nri Oral Nkịtị; Amalitela Prophylactic IV Dextrose ma ọ bụ Octreotide (Masks Mmalite) 3. Nlebanya dị mkpa na nyocha glucose Q1-2H: - Nri ụmụaka niile & Mwepụta nke okenye - Mwepụta / Glyburide: Admit for Minimum 24 Hours (Gụnyere) Nleba anya n'abalị. (Repaglinide/Nateglinide): Opekempe 8-12 Awa"]

    TreatHypo --> StartOctreotide["Mgbochi mgbochi ngwa ngwa: malite OCTREOTIDE (SANDOSTATIN) MGBE MGBE HYPOGLYCEMIC EPISODE mbụ (na-egbochi ọwa beta-cell voltaji-gated Calcium ọwa iji kwụsị ntọhapụ insulin): - Ndị okenye: 50 ruo 100 mcg awa anọ (SC) ọ bụla (SC) Ụmụaka: 1 ruo 1.5 mcg / kg (Max 50 mcg) SC ma ọ bụ IV kwa awa 6 (ma ọ bụ na-aga n'ihu IV Infusion na 50-125 ng / kg / min / 25-50 mcg / hr na Refractory Cases)"]

    StartOctreotide --> MaintenanceCare["1. Na-agba ọsọ mmezi IV Dextrose (D5W ma ọ bụ D10W) Titrated ka idobe Glucose ọbara 80-120 mg/dL (4.4-6.7 mmol/L) + Nri ọnụ na-anaghị egbochi ya ozugbo Teta 2. Lelee glucose ọbara kwa nkeji 30-60 ọ bụla, na-enyocha 3 ọ bụla. Potassium, & Insulin/C-Peptide Ọkwa (Kwenye maka hyperinsulinemia endogenous: Insulin dị elu + C-Peptide dị elu)"]

    ObserveProtocol --> DelayedDrop{"Ọbara Ọbara ọ na-agbada <60-70 mg/dL n'oge ọ bụla n'oge nlele?"}
    DelayedDrop -->|YES| TreatHypo
    DelayedDrop -->|NO: 100% Euglycemic for 24 Full Hours Without IV Dextrose or Octreotide| SafeDischarge["Ọ dị mma maka ịwụsa (mgbe mkpuchi nwa / isi mgbaka ma ọ bụ mmezi ọgwụgwọ gbasara akụrụ)"]

    MaintenanceCare --> WeanProtocol["Iwu nleba anya nke awa 24-OCTREOTIDE: Mgbe ịkwụsị Octreotide & IV Dextrose, lelee onye ọrịa nọ n'ụlọ ọgwụ na nri ọnụ naanị maka awa 12 ruo 24 zuru oke iji gosi na ọ nweghị nlọghachi azụ (ọkachasị na Renal Failure/Gimeburde)"]

Pathophysiology: Kedu ka Sulfonylureas si kpọchie pancreas "na" yana ka Octreotide si agbanyụọ ya "gbanyụọ"¶

1. The Pancreatic Beta-cell secretion Cascade (SUR1 -> K-ATP -> VGCC -> Insulin)¶

Na pancreas dị mma, mkpụrụ ndụ beta na-ahapụ insulin naanị mgbe glucose ọbara bilitere mgbe nri gasịrị:

1. ** Nchọpụta glucose anụ ahụ nkịtị : Mgbe glucose ọbara na-ebili n'elu 80 to 90 mg/dL, glucose na-abanye n'ime cell beta nke pancreatic GLUT2 Ndị na-ebugharị ma na-emeziwanye ya site na glycolysis na mitochondria n'ime ATP. Oke intracellular na-arị elu ** ATP-to-ADP ratio ** na-emechi ** ọwa potassium nwere mmetụta ATP (K-ATP ọwa) na akpụkpọ ahụ cell.
2. ** Depolarization na Calcium Influx : N'ihi na ebubo potassium ion nke ọma.K+) enwekwaghị ike ịpụpụ na cell, akpụkpọ ahụ beta-cell ** depolarizes ** (na-aghọ nke ọma). Depolarization eletrik a na-emepe ** L-ụdị Voltage-Gated Calcium Channels (VGCC, na-ekwe ka calcium extracellular (Ca2+) ịbanye n'ime cell beta wee kpalite ** exocytosis (njikọ na ntọhapụ) nke granules nzuzo insulin emebere tupu emebe *** (n'akụkụ equimolar C-peptide) banye na vein portal.
3. ** Kedu ka Sulfonylureas si kpochie mgba ọkụ : ọ bụla K-ATP ọwa bụ octamer wuru site na-akpụ akpụ anọ Kir6.2 subunits anọ gbara ya gburugburu ** Sulfonylurea Nnabata-1 (SUR1 akụkụ. Sulfonylureas (glipizide, glyburide, glimepiride, gliclazide) na meglitinides (** repaglinide, nateglinide*) na-ejikọta ya na **SUR1 subunit *** na ** mechanically kpochie ya K-ATP Mechie ọwa ***, na-agafe ihe mmetụta glucose nkịtị nke ATP nke cell. Ọbụna mgbe shuga ọbara onye ọrịa na-agbada 15 mg/dL na intracellular ATP na-adaba na ọkwa agụụ, nke K-ATP Ọwa na-emechi emechi, calcium na-abata, cell beta na-ewepụtakwa insulin na-egbu egbu ma na-egbochi imeju gluconeogenesis na glycogenolysis.

2. Ihe kpatara Octreotide ji bụrụ ọgwụ mgbochi anụ ahụ zuru oke (Nkwụchi Calcium n'okpuru ala)¶

N'ihi na sulfonylureas na-akpọchi SUR1 / K-ATP ọwa dị n'elu nke cascade, na-enyekwu glucose (D50W) naanị na-abawanye ATP intracellular yana ** na-eme ka influx calcium na insulin exocytosis** ozugbo ntinye nke sulfonylurea malitere imikpu ma ọ bụ dị larịị.

• ** Otu Octreotide si arụ ọrụ ***: ** Octreotide *** bụ analọgụ octapeptide sịntetik na-eme ogologo oge nke homonụ ** somatostatin. Mgbe a na-agbanye ya n'okpuru akpụkpọ anụ ma ọ bụ n'intravenous, Octreotide na-ejikọta ya na ** Somatostatin Subtype-2 na Subtype-5 (SSTR2 na SSTR5) G-protein jikọtara ọnụ na-anabata ya ** na akpụkpọ ahụ beta-cell pancreatic.
• ** Nkwụsị n'okpuru ala ozugbo ***: ịgbalite SSTR2 / SSTR5 ** na-egbochi ọwa calcium voltaji gated ozugbo (VGCCna-egbochi adenylate cyclase.cAMP) na distal insulin granule exocytosis . N'ihi na voltaji-gated calcium ọwa na-anọdụ ala ** downstream ** nke SUR1 / K-ATP Ọwa, ** Octreotide na-emechi ntinye calcium ma kwụsịchaa mmepụta insulin kpamkpam ọbụlagodi mgbe sulfonylurea ka na-ejikọta ya na ya. SUR1 onye nnabata.
• ** Ọgwụ mgbochi nke abụọ nke abụọ (Diazoxide) : Tupu Octreotide aghọọ ụkpụrụ nlekọta, ndị dọkịta na-eji ** Diazoxide (Proglycem, benzothiadiazine na-abụghị diuretic nke na-emepe ozugbo K-ATP ọwa. Taa, ** Octreotide na-ahọrọ nke ọma karịa Diazoxide** n'ihi na Diazoxide na-akpata nnukwu ** reflex tachycardia, hypotension systemic, njigide mmiri, na ịgba agbọ**, ebe Octreotide adịghị mma hemodynamically, ọ dị mfe inye ya n'okpuru akpụkpọ ahụ.50 to 100 mcg SC Q6H), ma na-arụkwa ọrụ nke ọma n'iwepụ mkpọka hypoglycemic ugboro ugboro.

Tebụlụ ntụle nna ukwu: Ọgwụ ọrịa shuga nke ọnụ na-emebiga ihe ókè (Olee Ndị Na-akpata Hypoglycemia na-egbu egbu?)¶

N'ihi na ndị ọrịa nwere ụdị ọrịa shuga 2dị nke abụọ na-aṅụ ọtụtụ ọgwụ ọnụ, ịchọpụta nke klas ọgwụ etinyere na-ekpebi ma onye ọrịa nọ n'ihe ize ndụ maka hypoglycemia na-egbu egbu:

Ụlọ ọgwụ Nzọụkwụ-Nzọụkwụ na EMS Dosing Protocol: Dextrose, Octreotide, na Decontamination¶

1. Mmezi Dextrose na-adabere n'intravenous (Na-ezere Necrosis Extravasation na nkwụghachi spikes)¶

Ọ bụrụ na onye ọrịa ahụ gosipụtara hypoglycemia na-akpata sulfonylurea.blood glucose < 60 mg/dL [3.3 mmol/L] ma ọ bụ ihe mgbaàmà ọ bụla neuroglycopenic), weghachi glucose ụbụrụ nkịtị ozugbo site na iji mkpokọta dextrose nke intravenous kacha dị irè iji belata mgbakasị akwara ma gbochie mkpali beta-cell pancreatic gabigara ókè:

• ** Okenye **: Onye nchịkwa 25 to 50 mL dextrose (50%)D50W, nwere 12.5 to 25 grams nke glucose) site na ahịrị peripheral ma ọ bụ Central IV (ma ọ bụ )100 to 250 mL dextrose bụ 10%D10W etinyere ngwa ngwa ihe karịrị nkeji 5 ruo 10, nke na-akpata obere phlebitis na usoro glycemic dị nro karịa. D50W).
• Ụmụaka na ụmụntakịrị: Atụla ala D50W banye n'ime akwara dị n'akụkụ obere nwatakịrị (oke hyperosmolarity ya.2,525 mOsm/L] na-ebute ọrịa sclerosis siri ike na necrosis anụ ahụ buru ibu ma ọ bụrụ na ọ na-apụ apụ). Kama, soro usoro ụmụaka "Iwu nke 50" (Dose in mL/kg x % Dextrose = 50, nke na-enye **0.5 grams/kg Ọbara glucose:
• 10% dextroseD10W, ọkachamma na ụmụ ọhụrụ na ụmụntakịrị) **: Onye nchịkwa 5 mL/kg (0.5 g/kg IV bolus (ruo 10 mL/kg [1 g/kgmaka oke ọdịdọ hypoglycemic).
• 25% dextroseD25W, umuaka tọrọ)**: Administer 2 mL/kg (0.5 g/kg* na 4 mL/kg (1 g/kg* IV bolus.
• ** Nlekọta Thiamine na ndị okenye na-eri nri na-adịghị mma ma ọ bụ ndị na-aṅụbiga mmanya ókè ***: N'ime ndị okenye nwere nsogbu ịṅụ mmanya na-adịghị ala ala ma ọ bụ erighị ihe na-edozi ahụ siri ike, na-enye 100 mg nke Thiamine intravenous (Vitamin B1) n'akụkụ (anaghị egbu oge) mbụ dextrose bolus iji gbochie nnukwu ** Wernicke encephalopathy **.

2. Kpọmkwem Octreotide (Sandostatin) Ọchịchị na Titration Infusion na-aga n'ihu.¶

Ozugbo emezigharịrị ihe omume hypoglycemic nke mbụ (ma ọ bụ ozugbo ị bịarutere ma ọ bụrụ na ụlọ ọgwụ EMS enyelarị IV dextrose ma ọ bụ shuga ọnụ maka obere glucose ọbara edekọtara), malite ** Octreotide ***:

1. ** Subcutaneous (SC) ma ọ bụ Intravenous (IV) Dosing (Standard First-Line Protocol)**:
2. ** Ndị okenye ***: **50 mcg to 100 mcg subcutaneously (SC) ma ọ bụ nwayọọ nwayọọ na intravenously (IV) kwa awa 6 *** opekata mpe ** awa 24 **. * (Ndụmọdụ ụlọ ọgwụ: injection subcutaneous na-enye mmetụta dị nro, na-adịgide adịgide karịa awa 6 ruo 8 ma na-ezere ọgbụgbọ dị nkenke ma ọ bụ bradycardia nke a na-ahụ mgbe ụfọdụ site na ntinye ngwa ngwa IV).
3. ** Ndị ọrịa ụmụaka ***: **1 to 1.5 mcg/kg (ruo oke nke 50 mcg kwa dose) subcutaneously (SC) ma ọ bụ IV kwa awa 6 ** ma ọ dịkarịa ala ** awa 24 **.
4. Mkpịsị Octreotide na-aga n'ihu na-aga n'ihu (maka oke ịdoụbiga mmanya ókè ma ọ bụ hypoglycemia refractory):
5. Ọ bụrụ na onye ọrịa loro ọtụtụ mbadamba ntọhapụ * Glucotrol XL ma ọ bụ * Glyburide * ma na-aga n'ihu na-enweta mbelata nke glucose n'ọbara n'etiti obere oge. Q6H doses, nye ya nke mbụ **50 to 100 mcg IV bolus *** (1 to 1.5 mcg/kg na ụmụaka) sochiri ozugbo ** na-aga n'ihu IV Octreotide infusion na 25 mcg/hour to 50 mcg/hour na ndị okenye *** (ma ọ bụ 50 to 125 ng/kg/minute [3 to 7.5 mcg/kg/hour] n'ime ụmụaka).
6. Mwepu nke eriri afọ maka mwepụta ngwa ngwa vs. Mwepụta agbatịpụrụ ( Glucotrol XL) mbadamba nkume ***:
7. Unyi arụrụ n'otu dose (1 g/kg, max 50 g: Na-elekọta ọnụ ma ọ bụrụ na onye ọrịa ahụ gosipụtara n'ime awa 1 ruo 2* nke ntinye ya ma na-amụ anya nke ọma ma na-echebe ụzọ ikuku ha.
8. ** Extended-Release Glipizide (* Glucotrol XL*) "GITS" Osmotic Pump Shells *: * Glucotrol XL * na-eji akpụkpọ anụ cellulose-acetate laser na-adịghị amị mkpụrụ ( N'ime nnukwu ịdoụbiga mmanya ókè nke * Glucotrol XL , na-enye ** unyi arụ ọrụ ruo awa 4 ruo 6 mgbe ntinyechara ya ** ma tụlee ** dum-bowel Irrigation (WBI) na ngwọta Polyethylene Glycol Electrolyte (PEG-ES na 1.5 to 2 L/hr na ndị okenye ma ọ bụ 25 mL/kg/hr n'ime ụmụaka) iji chụpụ shells osmotic pump shells na-adịghị etinye n'ime eriri afọ.

3. Isi 6 Ọgwụ Ọgwụ na Renal na-akpalite Sulfonylurea Coma na ndị okenye.¶

Ihe karịrị pasent 70 nke nnabata ụlọ ọgwụ maka nnukwu sulfonylurea hypoglycemia na ndị okenye karịrị afọ 65 ** na-eme na ndị ọrịa na-a theụ ọgwụ ha na-enye oge niile nke na-ezute otu n'ime ihe na-akpalite isii:

1. ** Ndị na-egbochi Enzyme CYP2C9Bactrim, Fluconazole, Metronidazole, Amiodarone***: cytochrome imeju P450 CYP2C9 bụ isi enzyme nke na-emepụta glipizide, glyburide, glimepiride na tolbutamide. Malite usoro ụbọchị 5 nke trimethoprim-sulfamethoxazole (Bactrim / Septra) maka ọrịa urinary tract ma ọ bụ *fluconazole *Difluca*maka ọrịa yisna-abawanye mkpokọta ọbara sulfonylurea site na 200% ruo 400% n'ime awa 48.
2. ** Ọgwụ nje fluoroquinoloneCiprofloxacin, Levofloxacin, Moxifloxacin***: gbochie mkpụrụ ndụ beta nke pancreatic ozugbo K-ATP Ọwa n'akụkụ sulfonylureas NA na-egbochi enzymes CYP, na-akpata na mberede, ama ama nnukwu dysglycemia na hypoglycemic coma (na-ebu ịdọ aka ná ntị igbe FDA).
3. • Gemfibrozil + RepaglinideCYP2C8 + OATP1B1 Mgbochi) : Inweta ọgwụ cholesterol fibrates ** gemfibrozil (Lopid) na meglitinide ** repaglinide (Prandin)* na-abawanye ọkwa repaglinide n'ọbara ** 8.1 okpukpu.810%*** ma na-agbatị ọkara ndụ ya site na elekere 1 ruo ihe karịrị awa iri na abụọ; Ọ bụrụ na itraconazole dịkwa, ọkwa na-ebili ** ugboro 19.
4. ** Ndị na-egbochi beta anaghị ahọpụta (Propranolol, Nadolol, Carvedilol*: kpuchie ihe ịrịba ama ịdọ aka ná ntị mbụ nke adrenergic nke ịdaba shuga dị n'ọbara ( igbochi ịma jijiji, obi mgbawa, na nchekasị ***, mgbe ị na-ahapụ ** cholinergic sweating [diaphoresis] na-emebibeghị **) wee gbochie beta-2-mediated hepatic glycogenolysis, yabụ onye ọrịa na-aga ozugbo site na inwe mmetụta nkịtị banye na mberede neuromaglycolysis.
5. **Salicylate (aspirin) ịdoụbiga mmanya ókè ma ọ bụ NSAID dị elu **: Wepụ sulfonylureas na saịtị njikọta albumin na plasma ma kpalie insulin nzuzo mgbe ọ na-egbochi gluconeogenesis.
6. ** mmerụ ahụ akụrụ dị njọ (AKI) ma ọ bụ ọrịa akụrụ na-aga n'ihu na-aga n'ihu (CKD): Mgbe ** glipizide* na-emezigharị n'ime imeju na ngwaahịa anaghị arụ ọrụ, ** glyburide (glibenclamide)** na glimepiride na-atụgharị ka ọ bụrụ ** metabolites hydroxylated na-arụ ọrụ.4-trans-hydroxyglyburide na M1) nke na-adabere kpamkpam na akụrụ maka nsị. Ọ bụrụ na okenye toro eto na glyburide na-etolite akpịrị ịkpọ nkụ site na gastroenteritis viral ma ọ bụ bido ACE inhibitor / NSAID, metabolites ndị ahụ na-arụ ọrụ na-agbakọta maka ụbọchị 3 ruo 5 **, na-ebute hypoglycemia na-adịghị akwụsị akwụsị.

Ihe ngosi ụlọ nyocha nke forensic: Iche Sulfonylurea ịdoụbiga mmanya ókè site na injection Insulin Exogenous (Insulin vs. C-Peptide)¶

Mgbe onye toro eto ma ọ bụ nwatakịrị gosipụtara hypoglycemia na-enweghị atụblood glucose < 40 mg/dL) na enweghị akụkọ ihe mere eme doro anya nke ịṅụ ọgwụ, ịbịaru ** otu ọbara ọbara ọbara na-acha uhie uhie / akwụkwọ ndụ akwụkwọ ndụ n'oge ihe omume hypoglycemic (tupu ma ọ bụ nri dị ka IV Dextrose nyere) ** maka ** Serum Insulin, C-Peptide, Beta-Hydroxybutyrate, na Sulfonylurea Toxicology Screen ** na-edozi nchoputa ozugbo:

• Hyperinsulinemia endogenous pancreatic (sulfonylurea / meglitinide ngafe ma ọ bụ insulinoma): N'ihi na mkpụrụ ndụ beta pancreatic nke onye ọrịa na-emepụta proinsulin, nke kewara 1:1 n'ime ** 1 molecule nke Insulin + 1 molecule nke C-Peptides, n'ime serum serum bụ n'ime serum. Elugoro *** (Insulin > 3 mcIU/mL na C-Peptide > 0.6 ng/mL N'oge hypoglycemia), yana plasma / mmamịrị ** ihuenyo sulfonylurea ** dị mma.
• ** Insulin ọgwụ na-apụ apụ (nke bụ eziokwu / obi ọjọọ / ihe mberede insulin ngafe): Insulin injectable azụmahịa (Humulin, Novolog, Lantus, Humalog) na-asachapụ na-enweghị C-peptide, insulin ịgbanye na-egbochikwa pancreas nke onye ọrịa. Ya mere, ** Serum Insulin bụ SKY-HIGH ebe Serum C-Peptide na-egbochi / enweghị ike ịchọpụta (< 0.2 ng/mL).

Nọmba mberede mpaghara na ụkpụrụ ụlọ ọrụ¶

Ajụjụ a na-ajụkarị¶

Kedu ihe kpatara inye dextrose intravenous?D50W) Mmụba shuga n'onwe ya na-eme ka shuga ọbara onye ọrịa daa karịa ka nkeji iri atọ gachara?¶

N'ime oke ọgwụ sulfonylurea, ọgwụ ahụ na-ejikọta ya na sel beta nke pancreatic, na-emechi ọwa potassium ha ka pancreas wee malite ịhapụ insulin mgbe niile. Mgbe dọkịta ma ọ bụ onye na-ahụ maka ahụike na-akwanye 50% dextrose (D50W) bolus n'ime akwara na-enyeghị Octreotide, mmụba mberede na shuga ọbara na-abanye n'ime sel beta nke pancreatic ma kpalite nnukwu mgbawa nke mmepụta insulin ọhụrụ. N'ime nkeji 30 ruo 60, nnukwu ebili mmiri nke insulin na-ekpochapụ glukos niile agbanyere ma mee ka shuga dị n'ọbara onye ọrịa laghachi azụ na ọkwa na-eyi ndụ egwu.

Kedu ka Octreotide si akwụsị shuga dị ala na Glipizide ma ọ bụ Glyburide ngafe?¶

Octreotide bụ ụdị sịntetik nke hormone somatostatin. Ọ bụ ezie na sulfonylureas dị ka glipizide na glyburide na-amanye ọwa potassium beta nke pancreatic na-emechi na mmalite nke ụzọ eletriki, mkpụrụ ndụ beta enweghị ike ịhapụ insulin ma ọ bụrụ na ion calcium na-esi na chanel calcium na-agbanye ọkụ na njedebe nke ụzọ ahụ. Octreotide na-ejikọ ya na ndị na-anabata somatostatin na cell beta wee mechie ọwa calcium voltaji na-agbadata ozugbo - gbanyụọ secretion insulin nke pancreatic n'ime nkeji oge ọbụlagodi ọgwụ sulfonylurea ka dị n'ime ahụ.

Kedu ihe kpatara na dọkịta enweghị ike ịmalite ntapu shuga na-egbochi intravenous (D5W ma ọ bụ D10W) ozugbo nwa na-eto eto nwere ike loro ọgwụ Glipizide mana ọ ka nwere shuga ọbara nkịtị?¶

Mgbe a na-akpọta nwatakịrị n'ọnụ ụlọ mberede mgbe ọ chọtara karama glipizide ma ọ bụ glyburide mepere emepe, ndị dọkịta anaghị amakarị ma nwatakịrị ahụ loro pill ma ọ bụ na-atụba ya n'ala. Ọ bụrụ na dọkịta na-ejikọta nwatakịrị ahụ asymptomatic ruo ihe mgbochi IV dextrose ma ọ bụ na-enye Octreotide ozugbo mgbe shuga dị n'ọbara na-adị mma, ntapu ahụ ga-eme ka ọ ghara ịdaba na shuga ọbara ruo ọtụtụ awa, na-eduga ndị otu ahụ ikwubi na ọ dịghị ọgwụ loro ma hapụ nwatakịrị ahụ n'ụlọ dịka pill na-arị elu - ma ọ bụ na-achọ ụbọchị ụlọ ọgwụ na-adịghị mkpa. Kama nke ahụ, a na-anabata ụmụaka asymptomatic maka awa 24 na nri nkịtị na-enweghị glucose IV ka ha na-elele shuga ọbara kwa awa 1 ruo 2, na-amalite IV Dextrose na Octreotide ozugbo ọdịda n'okpuru 60 ruo 70 mg/dL ga-apụta.

Kedu ihe kpatara ndị okenye ewerela otu ọgwụ Glyburide ma ọ bụ Glimepiride n'enweghị nsogbu ruo ọtụtụ afọ na-ada na mberede hypoglycemic coma mgbe ha malitechara ọgwụ nje Bactrim (Trimethoprim-Sulfamethoxazole) ma ọ bụ Fluconazole?¶

Sulfonylureas dị ka glipizide, glyburide na glimepiride na-agbaji n'ime imeju site na cytochrome P450 enzyme CYP2C9 ma na-ebupụ ya site na ndị na-ebufe akụrụ tubular. Ọgwụ nje na antifungals ndị a na-ahụkarị - ọkachasị Sulfamethoxazole-Trimethoprim (Bactrim/Septra), Fluconazole (Diflucan), Metronidazole, na Fluoroquinolones (ciprofloxacin, levofloxacin) - na-egbochi enzyme CYP2C9 nke ọma ma na-egbochi nnabata akụrụ, na-eme ka mbelata ọbara nke onye ọrịa na-abawanye ugboro 3 kwa ụbọchị. hypoglycemic coma ogologo oge.

Kedu ihe kpatara onye ọrịa ga-eji nọrọ n'ụlọ ọgwụ maka awa 12 ruo 24 ọzọ MGBE a kwụsịrị ịgba ọgwụ Octreotide ha na ntapu shuga IV?¶

Octreotide nwere ọkara ndụ nke naanị awa ole na ole, ebe sulfonylureas na ịdoụbiga mmanya ókè (karịsịa mwepụta Glipizide XL, Chlorpropamide na-arụ ọrụ ogologo oge, ma ọ bụ metabolites na-arụ ọrụ nke Glyburide na Glimepiride na ndị ọrịa nwere obere ọrụ akụrụ) nwere ike ijigide na pancreas maka awa 36 ruo 72+. Mgbe onye ọrịa na-anata Octreotide kwa awa 6, shuga ọbara ha ga-adị ka nke ọma n'ihi na Octreotide na-emechi pancreas. Naanị otu ụzọ ị ga-esi gosi na sulfonylurea emechaala ahụ ahụ bụ ịkwụsị Octreotide na IV dextrose wee nyochaa onye ọrịa nri naanị maka awa 12 ruo 24 zuru oke iji chọpụta na hypoglycemia anaghị alaghachi azụ.

Ntuziaka emetụtara¶

• Ihe mberede nke ọrịa shuga: enyemaka mbụ nke hypoglycemia na hyperglycemia
• Ọrịa mamịrị ketoacidosis (DKA) na hyperosmolar hyperglycemic steeti (HHS)
• Ọnọdụ akwụkwụ, ogologo ọdịdọ, yana ọgwụ nnapụta
• Mmeri akụrụ dị oke njọ, rhabdomyolysis, na mbelata mmamịrị gbara ọchịchịrị
• Enyemaka mbụ nsi na nchikota nsi

Isi mmalite na nduzi ọchịchị¶

• American College of Medical Toxicology (ACMT) & Ụlọ Ọrụ Nsi nke America: Ntụziaka Nkwenye dabere na ihe akaebe maka njikwa ụlọ ọgwụ nke ingestion sulfonylurea na ntuziaka ịkwakọba ọgwụ mgbochi maka Octreotide.
• American Diabetes Association (ADA) & Endocrine Society: * Standards of Care in Diabetes: Evaluation and Management of Adult and Pediatric Hypoglycemic Disorders and Sulfonylurea Toxicity*.
• Royal College of Medical Emergency (RCEM) & National Poisons Information Service (NPIS, United Kingdom): TOXBASE Clinical Protocol for Sulfonylurea Overdose and Category A Antidote Stocking of Octreotide.
• Ọgwụgwọ Extracorporeal na nsi (EXTRIP) & Clinical Toxicology Imekọ ihe ọnụ: Nduzi ụmụaka "Otu ọgwụ nwere ike igbu" Nduzi: Nleba anya elekere 24 a manyere amanyere na nnapụta Octreotide na ngosipụta Sulfonylurea.
• Òtù Ahụ Ike Ụwa (WHO): * Ụdị na njikwa nke Hypoglycemia siri ike sitere na Secretagogues Insulin Oral (Glibenclamide / Gliclazide)*.

• Ntuziaka a bụ maka ebumnuche ozi na anaghị edochi nyocha ahụike mberede ọkachamara, ndụmọdụ nchịkwa nsi, ma ọ bụ nleba anya n'ụlọ ọgwụ. N'ihi na otu mbadamba sulfonylurea nwere ike ime ka igbu oge, ihe ọdịdọ hypoglycemic na-emegharị ugboro ugboro na coma, anyị na-akwadosi ike ka ị nweta enyemaka enyemaka mbụ na usoro CPR site na International Federation of Red Cross and Red Crescent Societies (IFRC), Red Cross obodo gị, St John Ambulance, ma ọ bụ onye na-eweta mpaghara.