Medication-Induced Hypoglycemia (Low Blood Sugar)

Hypoglycemia (blood glucose levels below 70 milligrams per deciliter) is a serious medical emergency that requires prompt treatment to prevent neurological impairment.

Although hypoglycemia is a well-known adverse effect of antidiabetic medications, it also can develop in patients without diabetes who use certain other medications

Below are examples of the drugs that are implicated in drug-induced hypoglycemia.

Antidiabetic drugs

All antidiabetic medications are associated with a risk of hypoglycemia. Notably, an analysis of drug-induced adverse events reported to the Food and Drug Administration between 2004 and 2023 showed that both the commonly used oral antidiabetic drug metformin (generics only) and insulin drugs were associated with most cases of hypoglycemia.[1] Examples of these insulins include human insulin (HUMULIN R, other brands and biosimilars), insulin glargine (LANTUS, other brands and biosimilars) and insulin lispro (HUMALOG, other brands and biosimilars).

Among the other top antidiabetic drugs that induced hypoglycemia in the analysis were sulfonylureas (including glimepiride [generics only] and glipizide [GLUCOTROL XL and generics]) and the gliptin drug sitagliptin (BRYNOVIN, JANUVIA, ZITUVIO and generics).

Predictably, the risk of hypoglycemia is increased in individuals who take multiple antidiabetic drugs. Therefore, if an insulin user also takes a sulfonylurea (or another antidiabetic) drug and develops hypoglycemia, a lower dose of one of these drugs may be necessary.

Alcohol (ethanol)

Found in beer, hard liquor and wine, alcohol is considered a psychoactive drug. Hypoglycemia due to alcohol ingestion is a well-documented problem in diabetic patients, especially those on multiple antidiabetic medications, with a history of alcohol abuse or who have been fasting.[2]

Notably, alcohol-induced hypoglycemia can develop within 6 to 36 hours of ingesting even a moderate amount of alcohol in fasting individuals who are chronically malnourished.[3]

Because symptoms of hypoglycemia can resemble those of mild alcohol intoxication, it is important to suspect hypoglycemia first in impaired patients who have not eaten.

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors — including captopril (generics only), enalapril (EPANED, VASOTEC and generics) and lisinopril (QBRELIS, ZESTRIL and generics) — are widely used to treat heart failure and high blood pressure (hypertension).

Evidence from case studies shows that use of these drugs can increase the risk of severe hypoglycemia in diabetic patients.[4]

Beta blockers

Beta blockers are used to treat hypertension and other conditions including abnormal heart rhythms, angina and heart failure. Cardioselective (heart-targeted) beta blockers, such as atenolol (TENORMIN and generics) and metoprolol (KAPSPARGO SPRINKLE, LOPRESSOR, TOPROL-XL and generics), are less likely to trigger hypoglycemia than non-cardioselective beta blockers, including propranolol (HEMANGEOL, INDERAL LA, INNOPRAN XL and generics).[5] Nonetheless, cases of severe hypoglycemia have been reported with recommended doses of cardioselective beta blockers.

Therefore, all beta blocker users should be warned about their potential to induce hypoglycemia. Importantly, these drugs can mask many symptoms of hypoglycemia, such that sweating may be the only recognizable symptom.

Certain antiarrhythmic drugs

The abnormal heart rhythm drug disopyramide (NORPACE and generics) is a frequent cause of drug-induced hypoglycemia in patients without diabetes, even when it is taken alone, particularly in elderly patients and those with chronic kidney disease.[6]

Similarly, the antiarrhythmic drug quinidine (generics only) may trigger hypoglycemia in some patients.

Certain antibiotics

Case reports have linked doxycycline (ACTICLATE, DORYX, MONODOX, ORACEA and generics), an oral broad-spectrum tetracycline antibiotic, to hypoglycemia even in nondiabetic patients. In one case study, hypoglycemia occurred within a day of taking the first doxycycline dose.[7] In other cases, however, hypoglycemia occurred after six days of doxycycline use.

The broad-spectrum fluoroquinolone antibiotics — including ciprofloxacin (CIPRO and generics), levofloxacin (generics only) and ofloxacin (generics only) — are known to cause hypoglycemia, especially in patients taking antidiabetic drugs.[8] Fluoroquinolone labeling cautions that severe hypoglycemia associated with their use has led to coma or death in some patients.[9] Therefore, these antibiotics should be discontinued in patients who develop hypoglycemia. Importantly, as discussed in the June 2025 issue of Worst Pills, Best Pills News, fluoroquinolones also have been linked to hyperglycemia (elevated blood sugar levels) in some patients.[10]

Moreover, the antibiotic pentamidine (NEBUPENT, PENTAM and generics), used to treat pneumonia in immunocompromised patients, is commonly implicated in hypoglycemia.

Other drug examples

When used in high doses, the common pain medication acetaminophen (TYLENOL and generics) can cause hypoglycemia due to liver injury.

Hypoglycemia has been also reported in diabetic patients who took high doses of the nonsteroidal anti-inflammatory drug (NSAID) aspirin (BAYER, VAZALORE and generics).

Some case reports suggest that hypoglycemia is associated with use of other NSAIDs, such as ibuprofen (ADVIL, MIDOL LIQUID GELS, MOTRIN IB and generics) when used in conjunction with sulfonylureas,[11] as well as indomethacin (INDOCIN and generics).[12]

The labeling for the narcotic drug tramadol (CONZIP and generics) warns that cases of hypoglycemia leading to hospitalization have been reported with use of the drug.[13] It also warns that if hypoglycemia is suspected, blood sugar levels should be monitored and discontinuation of the drug should be considered.

Hydroxychloroquine (PLAQUENIL, SOVUNA and generics) — which is used to treat malaria, rheumatoid arthritis and lupus erythematosus — has been linked to hypoglycemia in patients who also were taking antidiabetic medications.[14]

What You Can Do

Always ask your clinician about potential adverse effects associated with your medications, and consider the possibility of drug-induced hypoglycemia.

If one of your medications is contributing to hypoglycemia, your clinician may suggest an alternative drug or lower the dose of your current one and ask you to monitor your blood sugar levels frequently to detect and manage hypoglycemia early.

If you are at risk of hypoglycemia, ask your clinician for an emergency ready-to-use glucagon (GVOKE and generics) kit, which can be injected in case of loss of consciousness due to hypoglycemia.[15]
 

References

[1] Li J, Wang Y, Yang X, et al. Drug-induced hypoglycemia: a disproportionality analysis of the FAERS database. Expert Opin Drug Saf. 2024;23(8):1061-1067.

[2] Vue MH, Setter SM. Drug-induced glucose alterations part 1: Drug-induced hypoglycemia. Diabetes Spectr. 2011;24(3):171-177.

[3] Pytliak M, Vargova V, Mechirov V. Drugs and hypoglycemia. In: Rigobelo EC, ed. Hypoglycemia - Causes and Occurrences. InTech Open; 2011:131-148.

[4] Cheung BMY, Ferner RE. Drug therapy: Special considerations in diabetes. In: Holt RIG, Cockram C, Flyvbjerg A, Goldstein BJ, eds. Textbook of Diabetes. Blackwell Publishing; 2010:410-423.

[5] Vue MH, Setter SM. Drug-induced glucose alterations part 1: Drug-induced hypoglycemia. Diabetes Spectr. 2011;24(3):171-177.

[6] Marks V, Derrick Teale J. Drug-induced hypoglycemia. Endocrinol Metab Clin North Am. 1999;28(3):555-577.

[7] Abdulle F, Dave H, Abushamma A, Diwakar A. Doxycycline induced hypoglycemia within 24 hours. J Endocr Soc. 2022;9(Suppl 1):bvaf149.1078.

[8] Tackett KL, Lancaster CS. Diabetes-related medication-induced hypoglycemia. J Pharm Pr. 2009;22(6):553-559.

[9] Bayer HealthCare Pharmaceuticals. Label: ciprofloxacin (CIPRO). September 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/019537s095,020780s050lbl.pdf. Accessed May 4, 2026.

[10] Drugs that can raise blood glucose levels. Worst Pills, Best Pills News. June 2025. https://www.worstpills.org/newsletters/view/1667. Accessed May 4, 2026.

[11] Sone H, Takahashi A, Yamada N. Ibuprofen-related hypoglycemia in a patient receiving sulfonylurea. Ann Intern Med. 2001;134(4):344.

[12] Maines E, Urru SAM, Leonardi L, et al. Drug-induced hyperinsulinemic hypoglycemia: An update on pathophysiology and treatment. Rev Endocr Metab Disord. 2023;24(6):1031-1044.

[13] Label: tramadol (CONZIP). December 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/022370s027lbl.pdf. Accessed May 4, 2026.

[14] Hydroxychloroquine: hypoglycaemia. Prescrire Int. 2015;24(161):156.

[15] Vella A. Hypoglycemia in adults without diabetes mellitus: Determining the etiology. March 25, 2025. UpToDate.