Moderate
Glibenclamide × Propranolol
Oral hypoglycemic agents. Sulfonylureas×Non-selective beta blocker
Mechanism
Beta-blockers mask adrenergic hypoglycaemia symptoms (tachycardia, tremor), leaving only sweating. Severe unrecognised hypoglycaemia risk rises in sulfonylurea-treated patients, especially older patients.
Symptoms
Sweating, confusion, vision changes, loss of contact. Adrenergic symptoms (tachycardia, tremor) are suppressed — the patient misses the hypoglycaemia.
Management
Do not prescribe propranolol in diabetes. Alternatives: cardioselective beta-blockers (metoprolol, bisoprolol, nebivolol) — minimally mask hypoglycaemia. Replace glibenclamide with modern glucose-lowering agents with lower hypoglycaemia risk: gliclazide MR, metformin, SGLT-2 inhibitors (dapagliflozin, empagliflozin), GLP-1 agonists (semaglutide, liraglutide). If the combination is unavoidable, teach the patient to recognise hypoglycaemia via sweating.
Sources
- ADA: Standards of Care in Diabetes – 2024 (Section 3, Prevention of Diabetes) (2024)– American Diabetes Association Professional Practice Committee. Standards of Care in Diabetes–2024. Diabetes Care 2024;47(Suppl 1):S43-S51.