CCBs inhibit insulin secretion, because calcium must enter beta-islet cells through L-type calcium channels in order for insulin to be released, resulting in hyperglycemia and alteration of myocardial fatty acid oxidation. Insulin increases cardiac output as a strong inotrope (not a vasopressor, notably) 5. While the molecular mechanisms of HDI are complex and not completely understood, it is important to note that insulin is not a specific antidote to CCB or BB agents. Insulin has been recognized as a positive inotrope since the 1920s, shortly after its isolation from the pancreas 4. High dose insulin therapy - How does it work? Cardiac output should be assessed with methods such as bedside ultrasonography to determine if hypotension is due to vasodilation for which increased vasopressors are needed, or due to cardiogenic shock for which inotropic agents, high dose insulin, lipid emulsion therapy, or ECMO may be needed. When these therapies fail, a medical toxicologist or poison control center should be consulted to assist with further therapy decisions such as: vasopressors/inotropes, HDI, or lipid emulsion therapy. This trend has continued through 2018, where calcium channel blockers and beta blockers were each listed in the top 10 substances associated with the largest number of fatalities 2.įirst line therapy for beta-blocker and calcium channel blocker overdose involves supportive care with IV fluids, atropine, calcium, and can sometimes include glucagon 3. In 2016, cardiovascular drugs as a class were the second leading cause of poisoning deaths reported to the National Poison Data System (NPDS), the majority of which were beta-blockers and calcium channel-blockers 1.

Call your local poison center for assistance administering HDI or for questions about any cardiotoxic ingestion at 1-80Ĭardiovascular drugs cause many poisoning deaths each year, primarily from acute overdose.

Note this is 10 times the usual dosing for DKA

The starting dose for HDI is 0.5-1 units/kg bolus then 0.5-1 unit/kg/hr drip.

HDI is more effective than vasopressors/inotropes alone.

HDI improves cardiac myocyte function by enhancing carbohydrate utilization within the myocyte and via other direct inotropic effects.

High dose insulin (HDI) is indicated in cardiogenic shock due to calcium channel blocker (CCB) or beta blocker (BB) overdose.

Glucagon as beta blocker antidote