Glucagon rescue is the emergency injection of glucagon in case of severe diabetic hypoglycemia. It is needed during seizures and/or unconsciousness by an insulin user who is unable at that point to help themselves. Glucagon will facilitate the release of stored glucose back into the bloodstream, raising the blood glucose level.
Rescue has been simplified by the development of the glucagon hypoglycemia rescue kit, consisting of:
- biosynthetic human glucagon, in a freeze dried form within a vial,
- a sturdy syringe, pre-filled with a sterile diluting solution, and
- a conspicuous red or orange colored plastic storage box, which includes instructions.
At the first signs of hypoglycemia, an insulin user should treat it immediately by consuming carbohydrate to restore blood glucose to safe levels (thereby preventing progression to severe hypoglycemia). However, not all insulin users can feel and recognize the early signs, particularly when sleeping. This can quickly lead to an emergency resulting in unconsciousness, inability to swallow, seizures, and in extreme cases death. In the past, treatment consisted of intravenous delivery of dextrose (glucose) usually in the emergency room; however, the delay in treatment due to emergency response and transport to a medical facility is life threatening.
- 1 Manufacturers of Glucagon Rescue Kits
- 2 Glucagon Rescue Instructions
- 3 Politics of Glucagon Rescue
- 4 Glucagon ‘Mini-dose’ Instruction
- 5 Further reading
- 6 References
- 7 External links
Manufacturers of Glucagon Rescue Kits
Glucagon rescue kits are manufactured by Novo Nordisk and Eli Lilly and Company. Novo Nordisk manufactures the GlucaGen HypoKit and Eli Lilly and Company manufactures the Glucagon Emergency Rescue Kit.
Glucagon Rescue Instructions
- open the vial by breaking off the plastic cap from the glucagon vial,
- inject the diluting solution into the vial of dry glucagon by first removing the cover from the syringe needle, and then injecting the diluting fluid from the syringe into the glucagon vial,
- swirl or shake to mix by withdrawing the syringe from the vial and swirl or shake slowly by hand until the white glucagon powder is dissolved in the fluid,
- inject the glucagon mixture by reinserting the needle back into the vial and drawing the glucagon mixture back into the syringe, and then injecting into the unconscious person's leg or abdomen muscle: the dosage is approximately half (Lilly kit: 500 µg; Novo Nordisk kit 0.5ml) for small children and approximately all (Lilly kit: 1000 µg; Novo Nordisk kit 1ml) for larger children and adults. Roll the unconscious person onto their side in case they vomit upon recovery, and then wait for the glucagon to take effect.
Controversial United States Instructions For Glucagon Rescue Kit
The steps to perform glucagon rescue and perhaps save a life are few and simple. However, the instructions that are supplied with the glucagon rescue kit are long, and potentially complicated to use. There are three counter-productive issues with the instructions:
- The instructions are folded tightly into a flat roll and glued at one end to keep the paper folded tight. When the instructions are unrolled, they are intimidating because of their length and small print.
- The instructions are divided in half. The left half is intended for the pharmacist, while the right half in intended for the user of the kit. The instructions for the pharmacist ask that the paper roll be cut in half, and that only the user half be included with the kit. However, it is rare for the pharmacist to do this, so the entire instructions are likely to be received by the user. In this case, reading starting from the left margin at the top will tell the reader about the chemical formula for glucagon, its organic sequence, pharmacokinetics, pharmacodynamics, indications and contraindications, etc. In an emergency situation, where a rapid response time equates to brain cells saved, the pharmacist’s instructions are counter productive.
- On the usage side of the instructions, the instructions for giving the injection state that the injection site should be cleansed with an alcohol swab prior to injection, and then the alcohol swab should be pressed to the injection site when removing the needle from the tissue. The swab is not included in the kit. While its use is a sanitary practice, it is not critical to administering the life-saving medicine. However some potential rescuers may erroneously decide to postpone rescue and wait for emergency personnel because they are unable to follow the instructions to give a sterile medical injection.
The kit has been carefully designed to facilitate rescue outside of a medical facility by non-medical personnel. While the instruction sheet may be helpful to a pharmacist and in prior training for glucagon administration, the sheet discourages the actual and proper use of the product.
The instructions are divided in half. The left half is intended for the pharmacist, while the right half in intended for the user of the kit. The instructions for the pharmacist ask that the paper roll be cut in half, and that only the user half be included with the kit. However, it is rare for the pharmacist to do this, so the entire instructions are likely to be received by the user. In this case, reading starting from the left margin at the top will tell the reader about the chemical formula for glucagon, its organic sequence, pharmacokenetics, pharmacodynamics, indications and contraindications, etc. before the time-critical usage instructions.
United Kingdom user instructions for glucagon rescue kit
These instructions come with the kit as supplied in the United Kingdom, and although expanded from the four necessary steps illustrated in instructional pictures inside the top cover of the glucagon rescue kit box, are still straightforward and less complicated to use than the United States instructions, as detailed above. However, the kit has been carefully designed to facilitate rescue outside of a medical facility by non-medical personnel, and the four necessary steps, as illustrated inside the plastic box, should be clear enough not to require these additional instructions in the case of a medical emergency.
Politics of Glucagon Rescue
Public awareness of other forms of life saving measures has increased dramatically in the past, such as:
- artificial respiration (or ‘mouth to mouth’)
- cardiopulmonary resuscitation (CPR)
- the Heimlich Maneuver, etc.
Glucagon ‘Mini-dose’ Instruction
The purpose of the off-label ‘mini-dose’ is to avoid an emergency condition that may require glucagon rescue. This might be needed in cases such as when a diabetic child is injected with insulin before breakfast, eats, and then vomits and cannot eat again: with the injected insulin working its way into the bloodstream and no carbohydrate to balance, there may soon be a hypoglycemic emergency.
To avoid severe hypoglycemia (or alternatively avoid a trip to the hospital for intravenous glucose), the glucagon from the emergency rescue kit can be used in a measured dose to maintain the blood glucose level. Instead of the glucagon emergency syringe and its large bore needle, a standard U-100 insulin syringe can be used. The recommended dose is:
- ages 2 years and under: 2 units (20 µg)
- age 2 to 15 years: 1 unit (10 µg) for each year of age (6 units for a 6 year old, etc.)
- age 15 years and older: 15 units (150 µg)
The mini-dose treatment should be repeated as necessary to maintain blood sugar until food can be eaten.
Medical studies have shown that the mini-dose rescue is tolerated well and effective.
The following scientific study papers may be of interest to those wishing to learn more about glucagon rescue in severe hypoglycemia:
- Kedia N. Treatment of severe diabetic hypoglycemia with glucagon: an underutilized therapeutic approach. Diabetes Metab Syndr Obes. 2011;4:337-46.
- Pearson T. Glucagon as a treatment of severe hypoglycemia: safe and efficacious but underutilized. Diabetes Educ. 2008;34:128-34.
- Frier BM. Hypoglycaemia in type 2 diabetes. Diabetic Hypoglycaemia Jun 2008;2:2-7.
- Harrism G, Diment A, Sulway M, Wilkinson M. Glucagon administration – underevaluated and undertaught. Pract Diabetes Int 2001;18:22-5.
- Namba M, Hanafusa T, Kono N, Tarui S. Clinical evaluation of biosynthetic glucagon treatment for recovery from hypoglycemia developed in diabetic patients. The GL-G Hypoglycemia Study Group. Diabetes Res Clin Pract 1993;19:133-8.
- Vukmir RB, Paris PM, Yeally DM. Glucagon: Prehospital therapy for hypoglycaemia. Ann Emerg Med 1991;20:375-9.
- Carstens S, Sprehn M. Prehospital treatment of severe hypoglycaemia: A comparison of intramuscular glucagon and intravenous glucose. Prehospital Disaster Med 1998;13:44-50.
- User information for ‘GlucaGen HypoKit’ from Novo Nordisk
- User information for ‘Glucagon Emergency Kit’ from Eli Lilly and Company
- ‘GlucaGen Hypo Kit’ elearning course
- Legal Rights of Students with Diabetes – American Diabetes Association
- Diabetes Care in Daycare: State Laws, Regulations, and Policies Related to Insulin and Glucagon Administration and Other Diabetes Care – American Diabetes Association
- Know Your Rights – American Diabetes Association
- Mini-Dose Glucagon Rescue for Hypoglycemia in Children With Type 1 Diabetes – Children with Diabetes
- Mini-Dose Glucagon Rescue for Hypoglycemia in Children With Type 1 Diabetes - Haymond and Schreiner. Diabetes Care 24(4):643-5.