What are the guidelines on high-dose insulin euglycemia (HIC) for the treatment of calcium channel blocker (CCB) toxicity?

Updated: Jan 04, 2021
  • Author: B Zane Horowitz, MD, FACMT; Chief Editor: Michael A Miller, MD  more...
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Only in a critical care area of the hospital (ED or ICU) owing to unstable hemodynamics associated with CCB toxicity, frequent requirements for central IV access/monitoring, and frequent glucose monitoring

Administration guidelines

Initial insulin bolus to saturate insulin receptors and assure adequate glucose availability:

  • 1 unit/kg regular human insulin IV
  • 1 amp (25 g) D50 IV: May hold if blood glucose >400 mg/dL (22.24 mmol/L)

Continuous infusion:

  • Insulin infusion: Place 500 U regular human insulin in 500 ml normal saline (1 unit/mL); start infusion at 0.5 units/kg/h; must be done with an infusion pump to avoid iatrogenic insulin overdose; reassess cardiac function and blood pressure every 15-30 minutes; increase infusion to 1-2 units/kg/h if no improvement after 30 minutes

  • Dextrose infusion: 0.5 mg/kg/h dextrose IV as either D5 (5 g of dextrose per 100 mL), D10 (10 g of dextrose per 100 mL), or D25 (25 g of dextrose per 100 mL); titrate to maintain blood glucose of 100-200 mg/dL; initial dextrose infusion requirement may vary depending on initial blood glucose and presence of underlying diabetes; higher concentrations of dextrose (ie, D25 and D50) require central IV administration due to local issue irritant effects of concentrated dextrose solutions


  • Bedside echocardiogram (ultrasound) for myocardial function: Ideally prior to HIE therapy, if possible; 30 minutes after initiation of HIE, if possible; 30 minutes after every dose increase, if possible
  • Continuous automated blood pressure monitoring
  • Foley catheter
  • Serial physical examinations, especially neurological status
  • Blood glucose finger-stick monitoring: Every 15-30 minutes until consistently 100-200 mg/dL for 4 hours, then every hour
  • Serum potassium : Every 1 hour
  • Lactic acid levels prior to Insulin then 1 hour after infusion

Therapeutic goals:

  • Normal myocardial ejection fraction (50%)
  • Blood pressure consistently higher than 90 mm Hg systolic
  • Improved mental status
  • Urine output 1-2 mL/kg/h
  • Decreased use of concomitant vasoactive drugs



  • It generally takes approximately 30 minutes to see effects from HIE

  • No ceiling dose of insulin has been established; the usual titration range is 0.5-2 units/kg/h

  • While cases have shown improved heart rate and conversion from heart block to sinus rhythm in temporal relationship to HIE administration, the main beneficial effect is on myocardial function (ie, ejection fraction and cardiac output), with subsequent improvement in blood pressure and perfusion

  • Mean duration of insulin therapy is 31 hours (range, 1-96 h)

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