Newer glucagon products provide additional options for the treatment of severe hypoglycemia.
We were asked to consult on a case involving a 68-year-old man with type 1 diabetes (T1D). He recently experienced a severe hypoglycemic event resulting in hospitalization. The patient currently lives independently with his wife of 40 years and has had T1D since the age of 12. When asked about his recent severe hypoglycemic event, he explained that he sat down in his recliner to rest and watch television after doing some work in his garage. His wife later found him in his chair unresponsive and called emergency medical services (EMS). When asked further about his hypoglycemia symptoms, the patient reported experiencing symptoms when his blood glucose “is in the low 50’s.” His most recent hemoglobin A1C was 6.6%. The patient reported eating three meals per day with no recent changes in his diet or amount of daily physical activity.
The patient’s medication regimen at the time of the consult consisted of the following:
- Insulin lispro (U-100) pen – 1 unit/8 grams CHO + 1 unit/50 mg/dL > 120 mg/dL
- Insulin glargine (U-100) pen – 30 units once daily at bedtime
- Lisinopril 20 mg once daily
- Atorvastatin 20 mg once daily
- Glucagon emergency kit
- Aspirin 81 mg daily
As is recommended by the American Diabetes Association (ADA), the patient did have an active prescription for glucagon.1 When the patient and his wife were asked about their Glucagon Emergency Kit, they reported never using it. The patient’s wife admitted to being apprehensive about using the Emergency Kit and preferred not to administer injections to her husband. In response, we shared information with the couple about two new glucagon products that may better meet their needs: Baqsimi® and GvokeTM. Baqsimi® is an intranasal formulation of glucagon,2, while GvokeTM is an injectable glucagon product available in an auto-injector that does not require reconstitution.3 Because the patient’s wife was generally uncomfortable with administering injections; they thought that Baqsimi® would be the best option for them. We counseled the patient and his wife about the proper use of Baqsimi® and reinforced education about hypoglycemia prevention, recognition, and appropriate treatment. The following recommendations were ultimately made for consideration:
- Provide a prescription for Baqsimi®.
- Consider raising the patient’s glycemic targets to avoid hypoglycemia for at least several weeks to reverse his hypoglycemia unawareness partially.1
- Consider initiating the use of a continuous glucose monitor (CGM) to help prevent future severe hypoglycemia events.
- Hypoglycemia unawareness can place patients at increased risk for severe hypoglycemic events. Glycemic targets should be reevaluated in patients with hypoglycemia unawareness and a history of severe hypoglycemia.
- Newer glucagon formulations that eliminate the need for reconstitution and allow for intranasal glucagon delivery offer additional options for caregivers with barriers to the use of traditional glucagon emergency kits.
- CGM can be auseful tool to prevent hypoglycemia, particularly in patients with hypoglycemia unawareness.
References for “Using Newer Glucagon Products”:
- American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes – 2020. Diabetes Care. 2020;43(Suppl. 1): S66-S76.
- Baqsimi(glucagon) nasal powder. Prescribing Information. Available at: baqsimi.com. Accessed October 7, 2020.
- Gvoke(glucagon) injection. Prescribing Information. Available at: gvokeglucagon.com. Accessed October 7, 2020.
Lynn C. Luu, PharmD Candidate 2022
Joshua J. Neumiller, PharmD, CDCES, FADCES, FASCP
Department of Pharmacotherapy
College of Pharmacy and Pharmaceutical Sciences
Washington State University
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