Limited supply of D50W has forced the need to identify alternative solutions.
Introduction: Diabetic emergencies are a frequent cause of ED visits, and as the diabetic population in the US increases, severe hypoglycemic emergencies including hypoglycemic or diabetic “shock” are becoming more common.
In the US, the mainstay of treatment for severe hypoglycemia consists of rapid intravenous push administration of highly concentrated dextrose (D50W, or 50% dextrose in water) to restore normal blood glucose levels. An “amp” of D50W, or 25g of glucose in a 50ml “jet” syringe is considered first line therapy. A severe, ongoing nationwide shortage of D50 has many hospitals scrambling to stock crash carts and provide rapid alternative solutions for hypoglycemic emergencies. Fears about under-treatment, delayed clinical effect or rebound hypoglycemia prevent many prescribers from considering less concentrated dextrose solutions. Interestingly, smaller doses of glucose in lower concentrations, administered over slightly longer periods of time have long been standard care in Europe and other parts of the world.(1) Could D10W be a viable solution to the ongoing shortage in the US? Let’s take a look at the evidence.
How it works: Glucose serves as the primary energy source for the body and a simple source of carbohydrate calories. Dextrose, the monosaccharide glucose, is utilized and stored by body tissues and metabolized to carbon dioxide and water with the release of energy.(2) When given intravenously, dextrose rapidly restores euglycemia. Notably, GLUT3, the primary glucose transporter in the brain, is saturated at normal blood glucose levels, meaning that higher quantities of glucose in blood have no additive mechanism for transport and no likely clinical benefit in the setting of acute hypoglycemia. A normal adult’s circulating blood volume contains less than 5g of glucose, meaning that one 25g dose of dextrose provides more than five times the amount in normal blood and leads to increased uptake by body tissues. This high dose suppresses both gluconeogenesis and glycogenolysis, which could result in rebound hypoglycemia.
The evidence for D10 vs. D50: The historical assumption about D50W is that it results in more rapid
resolution of hypoglycemia than less-concentrated solutions. Evidence suggests otherwise. One study compared administration of 5g incremental boluses of D10W (50ml) and D50W (10ml), repeated until patients achieved a GCS score of 15 and recovery. The two study groups had nearly identical times to recovery of around eight minutes, despite a total median dextrose dose of only 10g in the D10W group, versus 25g in the D50W group. Though the median post-treatment blood glucose was lower in the D10W arm (111mg/dL vs. 169 mg/dL), this was not felt to be clinically significant, as rates of rebound hypoglycemia were identical in both groups.(1)
In another pre-hospital study, 164 patients were given only 10g of D10W, and less than 20% of them required a second dose to achieve euglycemia.(3) There were no differences in adverse events reported in either study. There is also evidence to suggest that post-administration hyperglycemia or wide glycemic variability in the critically ill is a significant predictor of overall morbidity and mortality, making over-correction of hypoglycemia less favorable.(4)
Sudden, sharp increases in glucose concentrations have also been associated with hyperosmolar syndrome and increased morbidity and mortality in patients with comorbid CVA, MI, or sepsis. While no differences in adverse effects were reported in the above studies, it is well known that IV administration of hypertonic or higher osmolarity solutions carries a higher risk of complications including local tissue irritation and necrosis, extravasation injury and thrombophlebitis. D10W is thus less likely to carry a risk of such complications.
Dosing and administration: Administer 10g (100ml) of D10W solution from a 250ml premixed IV bag over two to five minutes. Even small gauge IV catheters (22 to 24g) can easily achieve flow rates above 30ml/min. Mental status, GCS and point-of-care blood glucose should be reassessed following administration of the bolus, and repeat 10g boluses can be administered every few minutes until improvement is achieved.
The bottom line: D10W is a safe, efficacious and inexpensive alternative to D50W for management of acute severe hypoglycemia. It is a reasonable alternative option during the ongoing D50W shortage, and is worthy of consideration as an equipotent alternative therapy in the long term.
References
- Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J. 2005;22(7):512-515.
- Dextrose 50% injection package insert. Hospira, Inc., Lake Forest, IL. 2019. Available at: https://www.pfizerinjectables.com/products/dextrose-50.
- Kiefer M, Gene H, Alter H, Barger J. Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehosp Disaster Med. 2014;29(2):190-194.
- Krinsley J. Glycemic variability: a strong independent predictor of mortality in critically ill patients. Crit Care Med. 2008;36(11):3008-3013.
