Journal of Medical Toxicology

, Volume 5, Issue 3, pp 139–143 | Cite as

The use of high-dose insulin-glucose euglycemia in beta-blocker overdose: A case report

  • Colin B. Page
  • L. Peter Hacket
  • Geoffrey K. Isbister
Toxicology Observations


The management of life-threatening beta-blocker toxicity and its associated low cardiac output state is clinically challenging. Previous case reports and case series describe the use of hyperinsulinemia/euglycemia therapy in mono-ingestions of calcium channel blockers and mixed ingestions, including calcium channel and beta-blockers. In this case report we describe the use of high-dose insulin (10 IU/kg per hour) in a case of massive metoprolol ingestion (5 g) in which hypotension was unresponsive to conventional therapies. Although the metoprolol concentrations measured in plasma were approximately 100–200 times therapeutic concentrations, the pharmacokinetics appeared to be similar to therapeutic metoprolol dosing.


high-dose insulin euglycemia beta-blocker toxicity 


  1. 1.
    Dollery C. Therapeutic Drugs, Volume 2. New York: Churchill Livingstone; 1991;156–164.Google Scholar
  2. 2.
    Wax PM, Erdman AR, Chyka PA, et al. B-blocker ingestion: An evidence-based consensus guideline for out-of-hospital management.Clin Toxicol 2005;43:131–146.Google Scholar
  3. 3.
    Reith DM, Dawson AH, Whyte IM, et al. Relative toxicity of beta blockers in overdose.J Toxicol Clin Toxicol 1996; 34(3):273–278.PubMedCrossRefGoogle Scholar
  4. 4.
    Dart RC. Medical Toxicology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2004;679–689.Google Scholar
  5. 5.
    Kerns W. Management of B-adrenergic blocker and calcium channel antagonist toxicity.Emerg Med Clin N Am 2007;309–331.Google Scholar
  6. 6.
    Reikeras O, Gunnes P, Sorlie D, et al. Haemodynamic effects of low and high doses of insulin during beta-receptor blockade in dogs.Clin Physiol 1985;5:455–467.PubMedCrossRefGoogle Scholar
  7. 7.
    Kerns W, Schroeder D, Williams C, et al: Insulin improves survival in a canine model of acute B-blocker toxicity.Ann Emerg Med 1997;29 (6):748–757.PubMedCrossRefGoogle Scholar
  8. 8.
    Krukenkamp I, Sorlie D, Silverman N, et al. Direct effect of high-dose insulin on the depressed heart after beta-blockade or ischemia.Thorac Cardiovasc Surg 1986;34:305–309.PubMedCrossRefGoogle Scholar
  9. 9.
    Holger JS, Engebretsen KM, Fritzlar SJ, et al. Insulin versus vasopressin and epinephrine to treat b-blocker toxicity.Clin Toxicol 2007;45(4):396–401.CrossRefGoogle Scholar
  10. 10.
    Baselt RC. Disposition of Toxic Drugs and Chemicals in Man, 6th ed. Seal Beach, CA: Biomedical Publications, 2002;700–703.Google Scholar
  11. 11.
    Megarbane B, Karyo S, Baud FJ. The role of insulin and glucose (hyperinsulinemia/euglycemia) therapy in acute calcium channel antagonist and b-blocker poisoning.Toxicol Rev 2004;23(4):215–222.PubMedCrossRefGoogle Scholar
  12. 12.
    Weinstein RS. Recognition and management of poisoning with beta-adrenergic blocking agents.Ann Emerg Med 1984;13:1123–1131.PubMedCrossRefGoogle Scholar

Copyright information

© American College of Medical Toxicology 2009

Authors and Affiliations

  • Colin B. Page
    • 1
  • L. Peter Hacket
    • 2
  • Geoffrey K. Isbister
    • 1
    • 3
    • 4
  1. 1.Department of Clinical Toxicology and PharmacologyCalvary Mater Newcastle HospitalNewcastleAustralia
  2. 2.Department of Clinical Pharmacology and ToxicologyPath West Laboratory Medicine WAPerthAustralia
  3. 3.Discipline of Clinical Pharmacology, Faculty of HealthUniversity of NewcastleNewcastleAustralia
  4. 4.Tropical Toxicology Unit, Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia

Personalised recommendations