Sulfonylurea (Glipizide/Glyburide) He nui te horopeta: He aha te Huka o te Toto ka Paheke Tonu I muri i te Huka¶

Sulfonylureas - tae atu ki te glipizide (Glucotrol, Glucotrol XL), glyburide / glibenclamide (DiaBeta, Glynase, Micronase), glimepiride (Amaryl), gliclazide (Diamicron), me te chlorpropamide - me te tere-mahi [mereglitinides] me te Pihitini (mereglitinides) nateglinide [Starlix]) he rongoa mo te mate huka Momo 2 a-waha e mohiotia ana ko insulin secretagogues. Kaore i rite ki te metformin (e mahi ana ma te whakapai ake i te maarama o te insulin me te kore e whakaheke i te huka toto ki raro i te tikanga o te tangata hauora), ka herea nga sulfonylureas ki te Sulfonylurea Receptor-1 (SUR1) wae iti o te pāhare pāporo tairongo ATP (K-ATP) nga hongere kei runga i nga pūtau beta pancreatic, e akiaki ana i te pancreas ki te maka i nga ngaru nunui, haere tonu o te insulin endogenous ki roto i te toto ahakoa te iti o te heke o te huka toto o te manawanui. No reira, ko nga sulfonylurea kei runga i te rarangi "Kotahi Pill Can Kill" mo nga tamariki: kotahi 5 mg ranei 10 mg te papa o te glipizide, te glyburide ranei i horomia ohorere e te kohungahunga - me nga pota paerewa o ia ra ka kohia i roto i te pakeke na te wharanga o te whatukuhu whakapeka, te taunekeneke tarukino ranei (pēnei i te trimethoprim-sulfamethoxazole [Bactrim] ranei fluconazole) - he take ** hohonu, roa, he kino tonu te roro, te neuroglycopenia, 4 ki te roro, te mate kino tonu. 72+ haora. Ko te mea kino atu, ko te rongoa i te nui o te sulfonylurea penei i te tauhohenga o te insulin ma te pana noa i nga boluses o te ** Intravenous Dextrose (Dextrose Intravenous).D50W ranei D25W) anake ka whakaoho i te mahanga kino o te hypoglycemia rebound: ko ia ngakinga o te huka IV e whakaihiihi ana i te pancreatic sulfonylurea-primed ki te tuku he nui ake te piki o te insulin, ka hoki te huka toto ki raro ki nga taumata whakamate (< 30 mg/dL ranei < 1.7 mmol/L) 30 ki te 60 meneti i muri mai ki te kore e tukuna e te hunga haumanu te rongoa rongoa motuhake, Octreotide (Sandostatin), ki te kati i te tukunga insulin pancreatic i te puna.

Mena kua horomia e te tamaiti tetahi pire mate huka kotahi, mena ka pohehe te pakeke e tango ana i te glipizide, te glyburide, te glimepiride, te gliclazide, te werawera, te wiri, te whawhai, te pohehe i te korero, te kore urupare ranei, waea atu ki to nama whawhati tata (911 i te United States me Canada, 112 puta noa i to tatou United Kingdom, 999) tau ohorere whaiaronga tonu, me te arotake ohorere mate huka, ketoacidosis mate huka me te ahua hyperosmolar, a te awhina tuatahi.

Mahia tenei inaianei¶

1. Waea atu ki a 911 / 112 / 999 me te Mana Paihana ka tirohia te huka toto ki te maihao mena kei a koe he mita: Mena kei te momoe te manawanui, kei te rangirua, kei te kopikopiko te kupu, te hopu, te kore whakautu ranei, waea atu ki te Ambulance Advanced Life Support (ALS). Mena kua horomia e tetahi kohungahunga, tamaiti iti ranei ara KOTAHI sulfonylurea me te pire meglitinide (glipizide, glyburide/glibenclamide, glimepiride, gliclazide, repaglinide), haria ki te tari whawhati tata tonu - me tono mo te 24-haora te whakaurunga o te sulfonylurea mo nga tamariki ki te hohipera i roto i te hohipera na te mea ka pa ohorere te mate hypoglycemia 8 ki te 18 haora i muri i te horomia o te pire (ina koa i te wa e moe ana te tamaiti i te po).
2. Mena ka oho te tangata ka taea e ia te horomia marie, hoatu he huka tere PLUS he paramanawa warowaiwa/poroti uaua i tenei wa tonu: Homai 15 to 20 grams o te huka tere mahi (120 mL [4 oz] o te wai huarākau, te houra kore kai ranei, 3 ki te 4 papa hukahuka, 1 punetēpu o te honi/huka rewa ki te wai), ka whai tonu i te paramanawa warowaiwa me te paramanawa pūmua (pērā i te pīnati pata pīnati, te hanawiti tīhi). Kaua rawa e hoatu he kai, he wai, he kiri ranei ki roto i te waha o te tangata e moe ana, e hopu ana, e kore e mohio.
3. ** Kia mohio koe he aha nga werohanga Glucagon (GlucaGen, Baqsimi, Gvoke) he maha nga wa ka taka, ka kino ake ranei nga tukinga rebound i roto i te paihana Sulfonylurea**: Ki te kore te tangata e mohio ana karekau ano he IV, ka taea e koe te whakamahi i te whawhati i roto i te muscular or intranasal Glucagon kit mena kei te ringa tetahi. Heoi, whakatupatohia nga kairorohiko ko glucagon e whakawhirinaki ana ki nga toa glycogen ate (e tere pau ana i te nui o te sulfonylurea) ME te glucagon e whakaihiihi tika ana i nga pūtau beta pancreatic ki te huna MORE te insulin, he maha nga wa ka puta te mate hypoglycemia kino i roto i te 30 ki te 45 meneti.
4. Mahiohio nga kaiparapara me nga taote ruuma whawhati tata ki te "IV Dextrose Rebound Trap" ka tono OCTREOTIDE: Me kii atu ki te roopu rongoa: *"He Sulfonylurea (Glipizide / Glyburide / Glimepiride) tenei ka nui te horopeta - ko te D50W boluses anake ka puta te pikinga o te insulin i muri i te iti o te huka toto.
5. Kaua e whakawhäitihia te kai i roto i te tamaiti kore tohu e tatari ana i raro i te matakitanga i te hohipera: Ina whakauruhia he tamaiti mo te tirotiro 24-haora i muri i te horomia i te pire sulfonylurea, whakaaetia te tamaiti ki te kai i te kai noa i te wa e tirotirohia ana te huka toto i te taha o te maihao i te taha o te moenga ia 1 ki te 2 haora. Heoi, Kaua e timata te dextrose intravenous prophylactic (D5W ranei D10W) maturuturu i roto i te tamaiti kore tohu me te huka toto noa, na te mea ka huna te huka IV prophylactic mehemea i horomia e te tamaiti te pire tae noa ki te wetenga o te maturuturu ka tukuna te tamaiti ki te kainga ki te aitua mate.
6. Tirohia etahi atu ipu rongoa a te manawanui mo te "Hidden Sulfonylurea Multipliers": Kawea mai ia pounamu pire ki te hohipera. I roto i nga pakeke pakeke me te mate huka Momo 2, ko te koma sulfonylurea e whakararu ana i te ora ka puta mai ehara i te tango pire taapiri, engari ma te tiimata i te patu paturopi, antifungal ranei (Trimethoprim-Sulfamethoxazole [Bactrim/Septra], Fluconazole [Diflucan], Ciprofloxacin/Levofloxamycinranei i te wharanga Clarixoxacin, Ranei i te whara Clarixoxacin/Levofloxacin. (AKI), e arai ana i te whakawāteatanga o ngā metabolites glyburide, glimepiride ranei.

Rakau whakatau: Te whakahaere i te sulfonylurea / meglitinide mo nga tamariki me nga pakeke me te Octreotide¶

flowchart TD
    Start["Ko nga Sulfonylurea e whakapaetia ana (Glipizide, Glyburide/Glibenclamide, Glimepiride, Gliclazide) Meglitinide ranei (Repaglinide, Nateglinide) Tuwhena / Whakaemi"] --> CheckBG{"Tirohia 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. Waro Whakahohe (1 g/kg) ki te < 1-2 haora i muri i te horomanga 2. Whakaaetia te kai-waha noa; KAUA E Whakamatau Prophylactic IV Dextrose or Octreotide (Masks Onset) 3. MANDATORY OBSERVATION WITH Q1-2H GLUCOSE CHECKS: - Katoa Pediatric Ingestions & Pakeke Whakaroa-Release / Glyburide: Whakaae mo te iti rawa o nga haora 24 (Kei roto i te moe mo te po) - Pakeke Moe mo te Po. (Repaglinide/Nateglinide): 8-12 haora te iti rawa"]

    TreatHypo --> StartOctreotide["WHAKATOKANGA KAUPAPA KAUPAPA: WHAKATAKIWA OCTREOTIDE (SANDOSTATIN) MURI I TE WANANGA HYPOGLYCEMIC TUATAHI (Ka aukati i nga Waahanga Konupora Beta-Cell Voltage-Gated Calcium Channels ki te aukati i te Rebound Insulin Release): - Pakeke: 50 ki te 100 mcg Subcutaneous (SC) ranei IV mo nga haora 1 iti rawa (SC) 4 ranei mo nga tamariki. 1.5 mcg/kg (Max 50 mcg) SC, IV ranei Ia 6 Haora (Ranei Infusion IV Tonu i te 50-125 ng/kg/min / 25-50 mcg/hr i roto i nga Take Refractory)"]

    StartOctreotide --> MaintenanceCare["1. Whakahaere Maintenance IV Dextrose (D5W or D10W) Titrated to Keep Blood Glucose 80-120 mg/dL (4.4-6.7 mmol/L) + Unrestricted Oral Diet Kia Oho 2. Tirohia te Toto Glucose Ia 30-60 Minutes Tae noa ki te Pumau, Katahi ka Tirohia ia 2 Haora Cretas 3. Ngā Taumata Insulin/C-Peptide (Whakaūhia te Hiperinsulinemia Endogenous: Te Insulin High + Te Peptide C-Teitei)"]

    ObserveProtocol --> DelayedDrop{"Ka heke te huka toto < 60-70 mg/dL ki tetahi waahi i te wa e tirotiro ana?"}
    DelayedDrop -->|YES| TreatHypo
    DelayedDrop -->|NO: 100% Euglycemic for 24 Full Hours Without IV Dextrose or Octreotide| SafeDischarge["He Haumaru mo te Putea (I muri i te Whakaaetanga Tamariki / Hinengaro Hinengaro, Whakarereketanga Rongoa Tango ranei)"]

    MaintenanceCare --> WeanProtocol["MANDATORY 24-HOUR POST-OCTREOTIDE ATURANGA MATITIAKI: I muri i te whakamutu i te Octreotide & IV Dextrose, Tirohia te Turoro i roto i te Hohipera i runga i te Kai-waha mo te 12 ki te 24 nga haora taapiri hei whakapumau karekau e hoki mai ano (ina koa ki te ngoikore o te renal, Glyburide ranei) / Glimepiride"]

Pathophysiology: Me pehea te maukati a Sulfonylureas te Pancreas "Kei" me te pehea e hurihia ai e Octreotide "Whakaweto"¶

1. Te Pancreatic Beta-Cell Secretion Cascade (SUR1 -> K-ATP -> VGCC -> Insulin)¶

I roto i te pancreas hauora, ka tukuna e nga pūtau beta te insulin ka piki noa te huka toto i muri i te kai:

1. Te Whakatairanga Tikanga Tikanga Tikanga Tikanga: Ina piki ake te huka toto ki runga 80 to 90 mg/dL, ka uru te huka ki roto i te pūtau beta pancreatic mā GLUT2 kaikawe, ka whakakorikoria e te glycolysis me te mitochondria ki ATP. Ko te pikinga o te ATP-ki-ADP ratio ka kati i nga ATP-tairongo pāhare pāporo (K-ATP takere) i runga i te membrane pūtau.
2. Whakahekenga me te Puka Konupora: Na te mea he pai te utu o te katote pāhare pāporo (K+) ka kore e taea te rere ki waho o te pūtau, ko te membrane pūtau-beta ka whakahekea (ka pai te utu). Ka whakatuwherahia e tenei whakahekenga hiko L-momo Ngaohiko-Gated Calcium Channels (VGCC), ka tuku i te konupūmā waho pūtau (Ca2+) ki te waipuke ki roto i te pūtau beta me te whakaoho i te exocytosis (whakakotahi me te tuku) o nga papura huna huna o te insulin i mua i te hanga (i te taha o te equimolar C-peptide) ki roto i te uaua o te tomokanga.
3. Pehea te Sulfonylureas te Kahaki i te Whakawhiti: Ia K-ATP Ko te hongere he octamer i hangaia mai i nga pore-hanga e wha Kir6.2 nga waahanga iti e karapotia ana e nga ture e wha Sulfonylurea Receptor-1 (SUR1) nga waahanga iti. Ko nga Sulfonylureas (glipizide, glyburide, glimepiride, gliclazide) me te meglitinides (repaglinide, nateglinide) ka hono tika ki te SUR1 subunit me mehini maukati te K-ATP katia te hongere, ka hipa katoa i te pūoko ATP glucose pūoko. Ahakoa ka paheke te huka toto o te manawanui 15 mg/dL me te ATP intracellular ka heke ki nga taumata matekai, te K-ATP Ka maukati te hongere, ka rere tonu te konupūmā ki roto, ka kumea tonu e te pūtau beta te nui o te insulin i te wa ano ka pehia te gluconeogenesis me te glycogenolysis.

2. He aha te Octreotide Ko te Tino Whakatau Aro-a-tinana (Te Poraka Konupora Raro)¶

Na te mea ka maukati nga sulfonylureas te SUR1 / K-ATP te hongere i te tihi o te cascade, ka nui ake te huka (D50W) ka whakanui noa i te ATP i roto i te pūtau ka ** ka whakanui ake i te urunga konupūmā me te insulin exocytosis** ina timata te kukū o te sulfonylurea ki te ruku, ki te paparahi ranei.

• Pehea te Mahi a Octreotide: Octreotide he tairitenga octapeptide waihanga roa o te taiaki somatostatin. Ina werohia i raro i te kiri, i roto ranei i te toto, ka herea a Octreotide ki Somatostatin Subtype-2 me Subtype-5 (SSTR2 a SSTR5) Ko nga kaiwhakawhiwhi G-pūmua-honoa kei runga i te kirikiri beta-cell pancreatic.
• Haerenga Whakararo Raro: Whakahohenga o SSTR2 / SSTR5 ** ka aukati tika i nga hongere konupūmā ngaohiko (VGCC) me te aukati i te adenylate cyclase (cAMP) me te exocytosis granule insulin distal**. No te mea ka noho nga hongere konupūmā ngaohiko i raro o te SUR1 / K-ATP te hongere, Ka tutakina e Octreotide te urunga o te konupūmā me te aukati katoa i te hunanga o te insulin ahakoa kei te herea tonu te sulfonylurea ki te SUR1 kaiwhakawhiwhi.
• Raina Tuarua Raina Whakatau (Diazoxide): I mua i te noho a Octreotide hei paerewa tiaki, i whakamahia e nga kairoro Diazoxide (Proglycem), he benzothiadiazine kore-diuretic e tuwhera tika ana K-ATP hongere. I tenei ra, Ko te Octreotide te tino pai ake i te Diazoxide na te mea he kino te mate o te Diazoxide reflex tachycardia, hypotension systemic, pupuri wai, me te ruaki, engari ko Octreotide he haumaru hemodynamically, he ngawari ki te tuku i raro i te kiri (50 to 100 mcg SC Q6H), me te tino whai hua ki te whakakore i nga tukinga hypoglycemic.

Te Ripanga Whakataurite Matua: Nga Taaru Mate Mate Awaha i te Taapiri (Ko Tehea Nga Mea Ka Paa Te Mate Mate?)¶

I te mea he maha nga wa ka kai nga turoro mate huka Momo 2 i nga rongoaa-waha maha, ma te tautuhi **ko tehea momo raau taero tika i whakaurua ka whakatau mena kei te tupono te manawanui ki te mate hypoglycemia whakamate:

Te Hohipera-a-Taahiraa me te Kawa Dosing EMS: Dextrose, Octreotide, me te Whakakore¶

1. Te Whakatikatika Dextrose Intravenous-Taimaha (Te karo i te Necrosis Extravasation me te Rebound Spikes)¶

I te wa e pa ana te turoro ki te hypoglycemia na te sulfonylurea (blood glucose < 60 mg/dL [3.3 mmol/L] me etahi tohu neuroglycopenic ranei), whakahokia tonu te hukahuka o te roro ma te whakamahi i te kukū whai hua iti rawa o te dextrose intravenous hei whakaiti i te irirangi o nga uaua me te whakaiti i te whakaihiihi nui o nga pūtau beta pancreatic:

• Pakeke: Whakahaere 25 to 50 mL o 50% Dextrose (D50W, kei roto 12.5 to 25 grams o te hukahuka) ma te raina IV i te taha maui, i te pokapū ranei (ranei 100 to 250 mL o 10% Dextrose [D10W] ka werohia tere i roto i te 5 ki te 10 meneti, ka iti ake te phlebitis me te anai glycemic ngawari ake i te D50W).
• Tamariki me nga Kohungahunga: Kaua rawa e pana D50W ki roto i te uaua peripheral o te tamaiti iti (toona tino hyperosmolarity [2,525 mOsm/L] ka puta te mate sclerosis uaua nui me te necrosis kiko kiko tonu ki te totoro). Engari, whai i te tamaiti "Ture 50" (Dose in mL/kg x % Dextrose = 50, e tuku ana 0.5 grams/kg o te huka):
• 10% Dextrose (D10W, pai ake i nga kohungahunga me nga tamariki nohinohi): Whakahaere 5 mL/kg (0.5 g/kg) IV bolus (tae noa ki 10 mL/kg [1 g/kg] mo te tino kaha o te hopu hypoglycemic).
• 25% Dextrose (D25W, tamariki pakeke): Whakahaere 2 mL/kg (0.5 g/kg) ki 4 mL/kg (1 g/kg) IV bolus.
• Thiamine Co-Administration in Malnourished or Alcoholic Pakeke: I roto i nga pakeke e mau tonu ana te mate inu waipiro me te mate kino kino ranei, whakahaere 100 mg o Intravenous Thiamine (Vitamin B1) i te taha (kaore e whakaroa) te dextrose bolus tuatahi hei aukati i te Wernicke encephalopathy.

2. Tikanga Tonu Octreotide (Sandostatin) me te Titration Infusion Tonu¶

I muri tonu i te whakatikatika i te waahanga hypoglycemic tuatahi (i te taenga mai ranei mena kua tukuna e te EMS i mua i te hohipera te IV dextrose, te huka-waha ranei mo te iti o te huka toto kua tuhia), timata te Octreotide:

1. Tukui Puawai (SC) ranei Intravenous (IV) Dosing (Kawa Raina Tuatahi Paerewa):
2. Pakeke: 50 mcg to 100 mcg i raro i te kiri (SC) me te āta whakaroto (IV) ia 6 haora mo te iti rawa 24 haora. (Aki haumanu: Ko te werohanga i raro i te kiri ka whai hua maeneene, pumau tonu mo te 6 ki te 8 haora, me te karo i te nausea poto me te bradycardia ka kitea i etahi wa me nga pananga IV tere).
3. Tauroro Pediatric: 1 to 1.5 mcg/kg (tae atu ki te morahi o 50 mcg ia horopeta) i raro i te kiri (SC) IV ranei ia 6 haora mo te iti rawa 24 haora.
4. Whakawowhanga Tonu Intravenous Octreotide (Mo te Whakanuia Whakanuia Nga Whakaaetanga, Te Hypoglycemia Refractory ranei):
5. Mena i horomia e te manawanui nga tini o nga papa tuku roa Glucotrol XL, Glyburide ranei, ka mau tonu te heke o te huka toto i waenga i te wa poto. Q6H horopeta, whakahaere i te tuatahi 50 to 100 mcg IV bolus (1 to 1.5 mcg/kg i roto i nga tamariki) ka whai tonu i te ** whaowhia IV Octreotide tonu i 25 mcg/hour to 50 mcg/hour i roto i nga pakeke** (ranei 50 to 125 ng/kg/minute [3 to 7.5 mcg/kg/hour] i roto i nga tamariki).
6. Ko te Whakakorenga i te Waehe mo te Whakaputa-Tuku-Tuku-Tuku-Toa (Glucotrol XL) Papa:
7. Waro Whakahohe Hohenga Kotahi (1 g/kg, max 50 g): Whakahaerehia ma te waha mena ka puta te turoro i roto i te 1 ki te 2 haora o te horomitanga me te tino oho me te tiaki i te huarahi rererangi.
8. Glipizide Tukua-Whakaroa (Glucotrol XL) "GITS" Osmotic Pump Shells: Glucotrol XL e whakamahi ana i te membrane cellulose-acetate-kore-whakarewa taiaho (Gastrointestinal Therapeutic System, GITS) e pupuhi ana i te glipizide ki waho i roto i te **16 haora i te wa e whakawhiti ana i te whekau. I roto i te nui o te horopeta nui o te Glucotrol XL, tukuna te Wao Whakahohe ki te 4 ki te 6 haora i muri i te tangohanga ka whakaaro ki te Whole-Bowel Irrigation (WBI) me te Polyethylene Glycol Electrolyte Solution (PEG-ES i 1.5 to 2 L/hr i nga pakeke ranei 25 mL/kg/hr i roto i nga tamariki) ki te horoi i nga anga papu osmotic kare i rukuhia ki waho o te kohanga whekau.

3. Ko te 6 nga mea nui mo te Taakaro-Taukino me te Renal Trigger e Whakatairanga ana i te Sulfonylurea Coma i roto i nga Pakeke Pakeke.¶

Neke atu i te 70 ōrau o te whakaurunga ki te hōhipera mō te sulfonylurea hypoglycemic kino i roto i nga pakeke neke atu i te 65 tau ka puta ki nga turoro e mau ana i o ratou horopeta kua whakaritea i ia wa ka pa ki tetahi o nga whakaohooho e ono:

1. ** CYP2C9 Kaitautoko Enzyme (Bactrim, Fluconazole, Metronidazole, Amiodarone)**: Hepatic cytochrome P450 CYP2C9 te whākōkī tuatahi e whakahāngai ana i te glipizide, te glyburide, te glimepiride, me te tolbutamide. Ko te tiimata i te akoranga 5-ra o trimethoprim-sulfamethoxazole (Bactrim / Septra) mo te mate urinary tract ranei fluconazole (Diflucan) mo te mate rewena ka piki ake te toto sulfonylurea e 200% ki te 400% i roto i te 48 haora.
2. Fluoroquinolone Antibiotic (Ciprofloxacin, Levofloxacin, Moxifloxacin): Aukati tika i te pūtau beta pancreatic K-ATP nga hongere i te taha o te sulfonylureas ME te aukati i te CYP enzymes, ka puta ohorere, tino kino te dysglycemia me te koma hypoglycemic (e mau ana i te Whakatupato Pouaka FDA).
3. Gemfibrozil + Repaglinide (CYP2C8 + OATP1B1 Blockade): Ko te tango i te rongoa fibrate cholesterol gemfibrozil (Lopid) me te meglitinide repaglinide (Prandin) ka piki ake nga taumata toto repaglinide 8.1-fold (810%) me te whakaroa i te haurua o te ora mai i te 1 haora ki te neke atu i te 12 haora; Mena kei te noho ano te itraconazole, ka piki ake nga taumata 19-whakaheke.
4. Kaore i whiriwhiria nga Beta-Arai (Propranolol, Nadolol, Carvedilol): Hukahia nga tohu whakatupato adrenergic aroha mo te heke o te huka toto (ka aukati i te wiri, te papouri, me te awangawanga, i te wa e mau tonu ana te werawera cholinergic [diaphoresis]) me te aukati i te beta-2-mediated hepatic glycogenolysis, no reira ka haere tika te manawanui mai i te ahua noa ki te neuroaglycopenic ohorere.
5. Salicylate (Aspirin) He nui te horopeta, he NSAID Poihe-teitei ranei: Hurihia nga sulfonylureas mai i nga waahi here albumin plasma me te whakaihiihi tika i te hunanga o te insulin me te aukati i te gluconeogenesis.
6. Mauiui Tatau Acute (AKI) or Progressive Chronic Kidney Disease (CKD): I te wa e whakangaohia ana te glipizide i roto i te ate ki nga hua karekau, ka huri te glyburide (glibenclamide) me te glimepiride ki nga metabolite hydroxylated hohe (4-trans-hydroxyglyburide a M1) ka whakawhirinaki katoa ki nga whatukuhu mo te whakaputanga. Mena ka mate te pakeke o te glyburide i te matewai mai i te gastroenteritis viral, ka timata ranei i te ACE inhibitor/NSAID, ka whakaemi aua metabolites kaha mo 3 ki te 5 ra, ka puta te mate huka korekore.

Tiwhikete Taiwhanga Forensic: Te Whakarereketanga o te Tuwhetawhe o te Sulfonylurea mai i te werohanga Insulin Exogenous (Insulin vs. C-Peptide)¶

Mena ka pa mai tetahi pakeke, tamaiti ranei ki te mate ohorere, karekau te hypoglycemia (blood glucose < 40 mg/dL) me te kore korero marama mo te tango pire, te tuhi i te kotahi ano ngongo toto whero-runga/matomato-runga i te wa o te wahanga hypoglycemic (i mua, i te taha matau ranei i te hoatutanga o te IV Dextrose) mo Serum Insulin, C-Peptide, Beta-Hydroxybutyrate, me te Sulfonylurea Toxicology Screen ka whakaoti tonu i te mate:

• Endogenous Pancreatic Hyperinsulinemia (Sulfonylurea / Meglitinide Overdose OR Insulinoma): No te mea ko nga pūtau beta pancreatic ake o te manawanui e hanga ana proinsulin, ka wehea te 1:1 ki 1 ngota ngota o te Insulin + 1 ngota ngota o C-Peptide, Ko te Peptide Serum Insulin ME te Serum kua tohuhiaC.Insulin > 3 mcIU/mL a C-Peptide > 0.6 ng/mL i te wa o te hypoglycemia), a he pai te plasma/mimi Sulfonylurea Screen.
• Ko te Insulin Insulin Insulin Exogenous (Mea / Kino / Akehia te Insulin Overdose): Ko nga insulins injectable arumoni (Humulin, Novolog, Lantus, Humalog) ka purea me te kore C-peptide, a ka pehia e te insulin i werohia te pancreas ake o te manawanui. No reira, Ko te Serum Insulin he SKY-HIGH i te Serum C-Peptide he KAUPAPA / KAUPAPA KAUPAPA (< 0.2 ng/mL).

Nga nama ohorere a rohe me nga tikanga umanga¶

Pātai auau¶

He aha te hoatu i te Dextrose whakaroto (D50W) ko te puhipuhi huka i a ia ano ka paheke te huka toto o te turoro i te 30 meneti i muri mai?¶

I te nui o te horopeta o te sulfonylurea, ka herea te rongoa ki nga pūtau beta pancreatic, ka kati o ratou takere pāhare pāporo kia kaha ai te pancreas ki te tuku tonu i te insulin. Ka peia e te taote, te paramedic ranei te 50% Dextrose (D50W) bolus ki roto i te uaua me te kore e hoatu he Octreotide, ka rere ohorere te piki o te huka toto ki roto i nga pūtau beta pancreatic, ka pa mai te pupuhi o te insulin hou. I roto i te 30 ki te 60 meneti, ka murua e taua ngaru nui o te insulin te hukahuka katoa i werohia, ka hoki ano te huka toto o te turoro ki nga taumata e mate ana.

Me pehea te aukati a Octreotide i te huka toto iti i roto i te taumahatanga o te Glipizide, Glyburide ranei?¶

Ko te Octreotide he putanga waihanga o te hormone somatostatin. Ahakoa ko nga sulfonylureas penei i te glipizide me te glyburide e akiaki ana i nga hongere pāhare pāporo o te pūtau beta pancreatic kia tutakina i te timatanga o te huarahi hiko, kare tonu e taea e te pūtau beta te tuku insulin ki te kore e rere nga katote konupūmā ki roto i nga hongere konupūmā ngaohiko i te pito o te huarahi. Ka herea e Octreotide ki nga kaiwhakawhiwhi somatostatin i runga i te pūtau beta, ka tutakina tika i nga hongere konupūmā ngaohiko o raro - ka whakaweto i te hunanga insulin pancreatic i roto i nga meneti ahakoa kei roto tonu te pire sulfonylurea i roto i te tinana.

He aha te take e kore ai e taea e te taote te tiimata i te whakaheke huka toto (D5W ranei D10W) i runga tonu i te kohungahunga kua horomia pea he pire Glipizide engari he huka toto tonu?¶

Ina kawea mai he tamaiti iti ki te ruma ohorere i muri i tana kitenga i tetahi pounamu tuwhera o te glipizide me te glyburide, he maha nga wa kare nga taote e tino mohio mena i horomia e te tamaiti tetahi pire, kua taka noa ranei ki te papa. Mena ka mauhia e te taote te tamaiti asymptomatic ki te whakaheke IV dextrose aukati, ka hoatu ranei i te Octreotide i te wa e tika ana te huka toto, ka huna e te maturuturu te maturuturu o te huka toto mo etahi haora, ka arahi te roopu ki te kii he kore he pire i horomia ka tukuna te tamaiti ki te kainga i te wa e piki ana te pire - me te hiahia ranei mo nga ra o te hohipera kaore e tika. Engari, ka whakauruhia nga tamariki asymptomatic mo te 24 haora i runga i te kai noa me te kore IV glucose i te wa e tirotirohia ana nga huka toto maihao ia 1 ki te 2 haora, ka tiimata te IV Dextrose me te Octreotide i te wa tonu ka puta te heke pono i raro i te 60 ki te 70 mg/dL.

He aha te hunga pakeke kua tango i taua horopeta o te Glyburide me te Glimepiride mo nga tau i ohorere ka taka ki roto i te koma hypoglycemic i muri i te tiimata o te rongoa paturopi Bactrim (Trimethoprim-Sulfamethoxazole) Fluconazole ranei?¶

Ko nga sulfonylureas penei i te glipizide, te glyburide, me te glimepiride ka pakaru i roto i te ate e te cytochrome P450 enzyme CYP2C9 ka peia e nga kaikawe tubular renal. Ko nga paturopi me nga antifungal noa - ina koa ko te Sulfamethoxazole-Trimethoprim (Bactrim/Septra), Fluconazole (Diflucan), Metronidazole, me Fluoroquinolones (ciprofloxacin, levofloxacin) - ka kaha te aukati i te CYP2C9 enzyme me te aukati i te waatea o nga whatukuhu, ka piki ake te toto o te manawanui ki nga wa o te mate huka. ka puta te koma hypoglycemic nui, roa.

He aha te take me noho te turoro ki te hohipera mo etahi atu 12 ki te 24 haora MURI i a ratou werohanga Octreotide me te whakaheke huka IV ka mutu?¶

He iti noa te haora o te Octreotide, engari ko te sulfonylurea i roto i te overdose (ina koa ko te Glipizide XL kua roa te tuku, te Chlorpropamide roa, me nga metabolites kaha o Glyburide me Glimepiride i roto i nga turoro he iti te mahi o te whatukuhu) ka herea ki te pancreas mo te 36 ki te 72+ haora. I te wa e whiwhi ana te manawanui ki a Octreotide ia 6 haora, ka tino rite te ahua o te huka toto na te mea kei te kati a Octreotide i te pancreas. Ko te huarahi anake hei whakaatu kua whakakorehia e te sulfonylurea te tinana ko te aukati i te Octreotide me te IV dextrose me te aro turuki i te manawanui i runga i nga kai noa mo te 12 ki te 24 haora katoa ki te manatoko karekau te hypoglycemia e hoki.

Nga kaiarahi e pa ana¶

• Nga mate ohorere: hypoglycemia me te hyperglycemia te awhina tuatahi
• Ketoacidosis mate huka (DKA) me te ahua hyperosmolar hyperglycemic (HHS)
• Te mate epilepticus, te hopu roa, me nga rongoa whakaora
• Te whara o te whatukuhu, te rhabdomyolysis, me te whakamatautau mimi pouri
• Ko te awhina tuatahi mo te paihana me te whakamatautau paihana

Nga puna me nga aratohu whai mana¶

• American College of Medical Toxicology (ACMT) & American's Poison Centres: He Aratohu Whakaaetanga I runga i nga Whakaaturanga mo te Whakahaerenga-waho-Hohipera mo te Ingestions Sulfonylurea me nga Aratohu Tiaki Tiaki Antidote mo Octreotide.
• American Diabetes Association (ADA) & Endocrine Society: Paerewa mo te Tiaki i te mate huka: Aromātai me te Whakahaere o nga Pakeke me te Pediatric Hypoglycemic Disorders me te Sulfonylurea Toxicity.
• Royal College of Emergency Medicine (RCEM) & National Poisons Information Service (NPIS, United Kingdom): TOXBASE Clinical Protocol for Sulfonylurea Overdose and Category A Antidote Stocking of Octreotide.
• Nga Maimoatanga Extracorporeal i roto i te Poisoning (EXTRIP) & Te Toxicology Haumanu Mahi Mahi tahi: Pediatric "Kotahi Pill Ka Whakamate" Aratohu: Mandatory 24-Hour Observation and Octreotide Rescue in Sulfonylurea Exposures.
• Te Whakahaere Hauora o te Ao (WHO): Tauira Whakatauira me te Whakahaere o te Hipoglycemia Tino mai i te Oral Insulin Secretagogues (Glibenclamide / Gliclazide).

Ko tenei aratohu mo nga kaupapa korero me te kore e whakakapi i te arotakenga hauora whawhati tata ngaio, te korero mo te Mana Paihana, me te tirotiro i te hohipera i roto i nga turoro. Na te mea ka taea e te papa sulfonylurea kotahi te whakaroa, te mau tonu o te mate hypoglycemic me te koma, ka tino taunaki matou ki te tango i tetahi awhina tuatahi me te akoranga CPR kua whakamanahia i roto i te International Federation of Red Cross and Red Crescent Societies (IFRC), to hapori Whero Whero o te motu, St John Ambulance, tetahi kaiwhakarato rohe whaimana ranei.