Insulin is the agent most commonly associated with severe hypoglycemia in patients evaluated in the emergency department. The hypoglycemic effects of excessive use of insulin may exceed the patient's caloric intake and precipitate hypoglycemia. The Diabetic Control and Complications Trial research group demonstrated that, although tighter glycemic control delayed the onset and progression of microvascular and neurologic complications in patients with type 1 diabetes, there were at least 120 episodes of treatment-requiring hypoglycemia per 100 patient years. 56 Therefore, intensive therapy directed at maintaining euglycemia increases the risk of hypoglycemia.

The pharmacokinetics of the various forms of insulin weigh heavily in management decisions. The rapidly acting but short-lived regular insulin produces relatively predictable hypoglycemia, whereas the long-acting insulins, such as NPH, have less predictable kinetic characteristics. Following large parenteral overdose, regular insulin manifests the unpredictable kinetics characteristic of the long-acting forms of insulin ( TabIeill184-2).

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