Glucagon in the treatment of severe hypoglycemia

It is the same hormone the pancreas normally makes, produced as a medicine. Its role is to instruct the liver to release glucose from its glycogen stores. This raises glucose without you needing to eat anything [1].

That is why it is the only treatment the people around you can give when the patient cannot swallow anything safely. It is not a medicine you take daily, but one you keep at hand and hope never to use. It is recommended for all patients treated with insulin, especially those at high risk of hypoglycemia [2].

When a patient with hypoglycemia cannot or will not swallow carbohydrates [2]. Typical situations are loss of consciousness, marked confusion, seizures and vomiting that makes treatment by mouth impossible.

You do not wait for confirmation with the glucometer if the situation is clear and the meter is not at hand. Glucagon given to a patient whose glucose was actually high does no significant harm. Delay in severe hypoglycemia can have dangerous consequences.

Three, by route of administration:

• Nasal powder, sprayed into one nostril (you do not need to breathe in).
• The prefilled pen or syringe, ready to inject.
• The classic form, a powder that must first be dissolved in the solvent from the kit.

The forms that need no preparation before use, namely the nasal one and the ready-to-inject one, are clearly preferred [3]. The reason is that a frightened person can give them more easily. In addition, the ready-made forms correct hypoglycemia just as effectively and can be given faster. A modern option is dasiglucagon, a glucagon analog that is stable in solution, in a prefilled pen [4]. The dose for young children may be lower and is set by the doctor [5].

Anyone, because no medical training is needed. The people who should be trained include family, roommates, school staff, coaches, daycare staff and coworkers [2].

The one instruction that should be repeated whenever possible is what not to do. Insulin is never given to a patient with hypoglycemia [6]. Show the glucagon box in advance to the people who are around you most often, let them read the instructions once and tell them where to find it when needed.

In a place everyone knows and that is easy to find without a long, careful search. A kitchen drawer or the bedside table works better than a first-aid kit shut away in a cupboard. Tell every person in the household where the glucagon box is [2].

Away from home, keep a box wherever you spend the most time, such as at school, at work or in your sports bag. Follow the storage temperature printed on the box, because in summer the temperature inside a car often exceeds the permitted limit. Do not keep your only spare in a place that is hard to reach.

Yes, like any medicine. Today's forms are more stable than the older ones, but they still expire at some point. Replacing it on time and storing it according to each product's instructions is recommended [2]. Check the expiration date on every box twice a year, at a moment that is easy to remember.

Expired glucagon is not thrown away before you have a new one. It is better to have a recently expired box than none at all. Ask for a new prescription in good time and replace the old one, especially if it is the form that has to be dissolved [7].

Glucose usually rises enough within 10 to 20 minutes of administration. The nasal form raises glucose similarly to the injectable one, in 16 minutes versus 13 minutes. The success rate is nearly 100% in both cases, when the full dose is given correctly [8] [9].

Medical help is called immediately after glucagon is given. If the person does not respond within 15 minutes, a second dose can be given while waiting for help, if one is available and the package insert allows it.

You turn the patient on their side, because nausea and vomiting are common [5]. When they come to and can swallow safely, you give fast-acting carbohydrates, then a snack that also contains starch or protein.

The reason for the snack is that glucagon empties part of the liver's glucose stores, and glucose can fall again once its effect wears off. Glucose is monitored for several hours, and the care team is informed the same day. Any episode that required glucagon changes the treatment plan.

Yes, it is the most common side effect. Nausea, with or without vomiting, occurs in about a third of administrations, at a similar rate for the nasal and the injectable form [8]. The nasal form can also cause a stinging nose, watery eyes or sneezing.

These effects pass on their own and are no reason to avoid giving glucagon. They are, however, a reason to turn the patient on their side right after giving it. A patient who vomits while lying on their back risks choking [5].

Not always, and the explanation is interesting. Glucagon works by drawing glucose out of the liver's glycogen stores. Alcohol does not block this release, but the making of new glucose, namely gluconeogenesis [5]. This prevents the glycogen stores from being rebuilt. As long as some glycogen stores remain, glucagon can still work [10].

The problem arises when the stores are empty. This happens after prolonged fasting, after long physical exertion or with chronic alcohol use. In these cases the hormone has nowhere to draw glucose from, and the correct treatment is emergency medical help with intravenous glucose [5]. The practical consequence stays the same. Hypoglycemia after alcohol is treated as an emergency, and glucagon is given, but without relying on it as the only solution. Call for medical help at the same time.