Severe Hypoglycemia Associated with Oral Sotalol Use in Two Children

Hypoglycemia is a rare but recognized side effect of anti-beta-adrenergic medications (beta-blockers) commonly used to manage arrhythmias in children. In 2014 a commercially available premixed solution of sotalol became available, and the use of oral sotalol in children has increased. Hypoglycemia associated with sotalol use has not been previously reported. Sotalol contains a racemic mixture of its D- and L-enantiomers and although it primarily acts to block Ikr (potassium channels), the L-enantiomer has nonselective anti-beta-adrenergic effects. Common sources such as Lexidrugs® and UpToDate®, used to obtain information regarding adverse drug events and precautions, do not list hypoglycemia as a side effect of sotalol. We report 2 unrelated toddlers with severe hypoglycemia, altered mental status, and seizures with sotalol use requiring hospitalization. In both children, hypoglycemia occurred in morning hours after decreased oral intake. Complete work-up for alternative etiologies for hypoglycemia was negative. It is important for prescribing physicians to be aware of this rare but serious side effect and to counsel patients and families appropriately. Key Teaching Points • Sotalol is a racemic mixture of 2 enantiomers. In addition to potassium channel blockade, sotalol has nonselective beta-adrenergic blocking effects. • Severe hypoglycemia can occur with sotalol use, particularly in young children and toddlers after decreased oral intake, after prolonged fasting, or with intercurrent illness. • Counseling should be provided to parents regarding hypoglycemia risks.