Avoidable iatrogenic hypoglycemia in patients on peritoneal dialysis: the risks of nonspecific glucose monitoring devices and drug-device interaction

Document Type

Journal Article

Publication Date



Journal of patient safety








BACKGROUND AND OBJECTIVES: Health care professionals (HCPs) depend upon "point-of-care" (POC) glucometers to provide appropriate treatment in emergency and hospital environments. Most devices located in these settings use nonspecific test strip methodology (NSTSM), which is unable to distinguish glucose from nonglucose sugars, including maltose. This flaw can result in erroneous administration of insulin and harm to patients. Icodextrin is a colloidal osmotic agent used in peritoneal dialysis (PD) solutions to augment ultrafiltration and waste removal. The main metabolite of icodextrin is maltose. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Three representative case reports of inappropriate medical action related to in-hospital use of NSTSM monitoring in PD patients using icodextrin are provided to emphasize importance of this interaction and HCP awareness. RESULTS: PD patients using icodextrin before hospitalization exhibited marked discrepancy between blood glucose (BG) measurements obtained from POC-NSTSM glucometers and those obtained by glucose-specific methods in clinical chemistry laboratories leading to inappropriate administration of insulin by HCPs and symptomatic hypoglycemia in all patients. None of the patients received icodextrin during hospitalization. CONCLUSIONS: Non-nephrology HCPs are unaware that POC glucometers are nonglucose specific and do not possess comprehensive knowledge of drug metabolism, particularly for uncommonly seen agents. The case reports highlight the absolute need for use of glucose-specific assays in BG determinations for patients using icodextrin within 2 weeks of hospitalization. To avoid future devastating consequences including severe hypoglycemia, coma, or death related to the drug-device interaction described, hospital protocols should require that all PD patients' BGs are measured in central chemistry laboratories.