GLOO-ka-gon

• Acute management of severe hypoglycemia.
• Facilitation of radiographic examination of the GI tract.

Unlabeled Use:

• Beta-blocker overdose.
• Calcium channel blocker overdose.

• Stimulates hepatic production of glucose from glycogen stores (glycogenolysis).
• Relaxes the musculature of the GI tract (stomach, duodenum, small bowel, and colon), temporarily inhibiting movement.
• Has positive inotropic and chronotropic effects.

• Increase in blood glucose.
• Relaxation of GI musculature, facilitating radiographic examination.

Absorption: Well absorbed following IM, intranasal, and subcut administration; IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism/Excretion: Extensively metabolized by the liver, plasma, and kidneys.

Half-life: 8–18 min.

Contraindicated in:

• Hypersensitivity
• Pheochromocytoma
• Insulinoma.

Use Cautiously in:

• Prolonged fasting, starvation, adrenal insufficiency, or chronic hypoglycemia (low levels of releasable glucose)
• When used to inhibit GI motility, use cautiously in geriatric patient with cardiac disease or diabetics
• OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk
• Lactation: Safety not established in breastfeeding
• Pedi: Children <4 yr (safety and effectiveness of nasal powder not established).

CV: hypotension.

Derm: necrolytic migratory erythema.

EENT: epistaxis, eye redness, itchy eyes, itchy throat, nasal congestion, nasal discomfort, nasal itching, rhinorrhea, sneezing, watery eyes.

GI: nausea, vomiting.

Neuro: headache.

Resp: cough.

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS).

Drug-Drug:

• Large doses may ↑ the effect of warfarin.
• Negates the response to insulin or oral hypoglycemic agents.
• Phenytoin inhibits the stimulant effect of glucagon on insulin release.
• Hyperglycemic effect is intensified and prolonged by epinephrine.
• Patients on concurrent beta blocker therapy may have a greater ↑ in heart rate and BP.

Hypoglycemia

• IV, IM, SC (Adults and Children >25 kg): 1 mg; may be repeated in 15 min if necessary.
• SC (Adults and Children 12 yr): Gvoke — 1 mg; may be repeated in 15 min if necessary.
• IV, IM, SC (Children <25 kg): 0.5 mg or 0.02–0.03 mg/kg; may be repeated in 15 min if necessary.
• IV, IM, SC (Children >6 yr and unknown weight): 1 mg; may be repeated in 15 min if necessary.
• IV, IM, SC (Children <6 yr and unknown weight): 0.5 mg or 0.02–0.03 mg/kg; may be repeated in 15 min if necessary.
• SC (Children 2–12 yr and 45 kg): Gvoke — 1 mg; may be repeated in 15 min if necessary.
• SC (Children 2–12 yr and <45 kg): Gvoke — 0.5 mg; may be repeated in 15 min if necessary.
• Intranasal (Adults and Children 4 yr): 3 mg (one actuation) in one nostril; may be repeated in 15 min if necessary.

Radiographic Examination of the GI Tract

• IM, IV (Adults): 0.25–2 mg; depending on location and duration of examination (0.5 mg IV or 2 mg IM for relaxation of stomach; for examination of the colon 2 mg IM 10 min before procedure).

Antidote (unlabeled)

• IV (Adults): Beta blocker overdose — 50–150 mcg (0.05–0.15 mg)/kg, followed by 1–5 mg/hr infusion. Calcium channel blocker overdose — 2 mg; additional doses determined by response.

• May be given subcut, IM, or IV. Reconstitute with diluent supplied in kit by manufacturer. Inspect solution prior to use; use only clear, water-like solution. Solution is stable for 48 hr if refrigerated, 24 hr at room temperature. Unmixed medication should be stored at room temperature.
  • Administer supplemental carbohydrates IV or orally to facilitate increase of serum glucose levels.
• SC: Gvoke solution is clear and colorless to pale yellow; do not administer if solution is discolored or contains particulate matter. Inject in lower abdomen, outer thigh, or outer upper arm.
• Intranasal: Administer by inserting tip into one nostril and pressing device plunger all the way in until green line is no longer showing. Dose does not need to be inhaled. Call for emergency assistance immediately after administering dose. When patient responds to treatment, give oral carbohydrates.

IV Administration:

• IV Push: Reconstitution: Reconstitute each vial with 1 mL of an appropriate diluent. For doses 2 mg, use diluent provided by manufacturer. For doses >2 mg, use sterile water for injection instead of diluent supplied by manufacturer to minimize risk of thrombophlebitis, CNS toxicity, and myocardial depression from phenol preservative in diluent supplied by manufacturer. Reconstituted vials should be used immediately.Concentration: Not exceed 1 mg/mL.
• Administer at a rate not exceeding 1 mg/min. May be administered through IV line containing D5W.Rate:
• Reconstitution: Reconstitute vials as per directions above (use sterile water for injection).
  Diluent: Further dilute 10 mg of glucagon in 100 mL of D5W.Concentration: 0.1 mg/mL.Continuous Infusion:
• Rate: See Route/Dosage section.
• Y-Site Compatibility: naloxone.

Baqsimi, GlucaGen, Gvoke

Therapeutic Classification: hormones

Pharmacologic Classification: pancreatics

(Generic available)

• Nasal powder: 3 mg/device;
• Powder for injection: 1-mg (equivalent to 1 unit) vials as an emergency kit for low blood glucose and as a diagnostic kit;
• Solution for subcutaneous injection (Gvoke) (prefilled syringes and prefilled autoinjectors): 0.5 mg/0.1 mL; 1 mg/0.2 mL;

• Assess for signs of hypoglycemia (sweating, hunger, weakness, headache, dizziness, tremor, irritability, tachycardia, anxiety) prior to and periodically during therapy.
• Assess neurologic status during therapy. Institute safety precautions to protect patient from injury caused by seizures, falling, or aspiration. For insulin shock therapy, 0.5–1 mg is administered after 1 hr of coma; patient usually awakens in 10–25 min. If no response occurs, repeat the dose. Feed patient supplemental carbohydrates orally to replenish liver glycogen and prevent secondary hypoglycemia as soon as possible after awakening, especially pediatric patients.
• Assess nutritional status. Patients who lack liver glycogen stores (starvation, chronic hypoglycemia, adrenal insufficiency) will require glucose instead of glucagon.
• Assess for nausea and vomiting after administration of dose. Protect patients with depressed level of consciousness from aspiration by positioning on side; ensure that a suction unit is available. Notify health care professional if vomiting occurs; patient will require parenteral glucose to prevent recurrent hypoglycemia.

• Monitor serum glucose levels throughout episode, during treatment, and for 3–4 hr after patient regains consciousness. Use of bedside fingerstick blood glucose determination methods is recommended for rapid results. Follow-up lab results may be ordered to validate fingerstick values, but do not delay treatment while awaiting lab results, as this could result in neurologic injury or death.
  • Large doses of glucagon may cause a ↓ in serum potassium concentrations.

• Risk for injury (Indications).
• Noncompliance (Patient/Family Teaching).

• Teach patient and family signs and symptoms of hypoglycemia. Instruct patient to take oral glucose as soon as symptoms of hypoglycemia occur; glucagon is reserved for episodes when patient is unable to swallow because of decreased level of consciousness.
• Home Care Issues: Instruct family on correct technique to prepare, draw up, and administer injection. Health care professional must be contacted immediately after each dose for orders regarding further therapy or adjustment of insulin dose or diet.
• Advise family that patient should receive oral glucose when alertness returns.
• Instruct family to position patient on side until fully alert. Explain that glucagon may cause nausea and vomiting. Aspiration may occur if patient vomits while lying on back.
• Instruct patient to check expiration date monthly and to replace outdated medication immediately.
• Review hypoglycemic medication regimen, diet, and exercise programs.
• Patients with diabetes mellitus should carry a source of sugar (such as a packet of sugar or candy) and identification describing disease process and treatment regimen at all times.
• Advise patient to notify health care professional if pregnancy is suspected or if breast feeding.

• Increase of serum glucose to normal levels with improved level of consciousness.
• Smooth muscle relaxation of the stomach, duodenum, and small and large intestine in patients undergoing radiologic examination of the GI tract.

NDC Code^*

• 0002- Eli Lilly and Company
  • 0002-6145- Baqsimi
    • 0002-6145-11- 1 TUBE in 1 CARTON (0002-6145-11) > 1 BOTTLE, UNIT-DOSE in 1 TUBE (0002-6145-02) > 1 POWDER in 1 BOTTLE, UNIT-DOSE (0002-6145-01)

• 0002- Eli Lilly and Company
  • 0002-6145- Baqsimi
    • 0002-6145-27- 2 TUBE in 1 CARTON (0002-6145-27) > 1 BOTTLE, UNIT-DOSE in 1 TUBE (0002-6145-02) > 1 POWDER in 1 BOTTLE, UNIT-DOSE (0002-6145-01)

• 0002- Eli Lilly and Company
  • 0002-8031- Glucagon
    • 0002-8031-01- 1 KIT in 1 KIT (0002-8031-01) * 1 mL in 1 VIAL (0002-7529-01) * 1 mL in 1 SYRINGE (0002-7530-01)

• 0169- Novo Nordisk
  • 0169-7065- GlucaGen HypoKit
    • 0169-7065-15- 1 KIT in 1 KIT (0169-7065-15) * 1 mL in 1 VIAL, GLASS * 1 mL in 1 SYRINGE, GLASS

• 0597- Boehringer Ingelheim Pharmaceuticals, Inc.
  • 0597-0053- GlucaGen
    • 0597-0053-45- 10 VIAL in 1 CARTON (0597-0053-45) > 1 mL in 1 VIAL

• 0597- Boehringer Ingelheim Pharmaceuticals, Inc.
  • 0597-0260- GlucaGen
    • 0597-0260-10- 1 KIT in 1 KIT (0597-0260-10) * 1 mL in 1 VIAL, GLASS (0597-0053-01) * 1 mL in 1 VIAL, GLASS (0597-0265-94)

• 43742- Deseret Biologicals, Inc.
  • 43742-0252- Glucagon
    • 43742-0252-1- 30 mL in 1 PACKAGE (43742-0252-1)

• 43742- Deseret Biologicals, Inc.
  • 43742-0734- Glucagon
    • 43742-0734-1- 30 mL in 1 BOTTLE, DROPPER (43742-0734-1)

• 63323- Fresenius Kabi USA, LLC
  • 63323-593- Glucagon
    • 63323-593-03- 1 KIT in 1 CARTON (63323-593-03) * 1 mL in 1 VIAL, SINGLE-USE (63323-596-03) * 1 mL in 1 VIAL, SINGLE-USE (63323-185-03)

• 63323- Fresenius Kabi USA, LLC
  • 63323-594- Glucagon
    • 63323-594-03- 1 KIT in 1 CARTON (63323-594-03) * 1 mL in 1 VIAL, SINGLE-USE (63323-596-06) * 1 mL in 1 VIAL, SINGLE-USE (63323-185-03)

• 63323- Fresenius Kabi USA, LLC
  • 63323-596- Glucagon
    • 63323-596-16- 10 VIAL, SINGLE-USE in 1 TRAY (63323-596-16) > 1 mL in 1 VIAL, SINGLE-USE (63323-596-08)

• 63323- Fresenius Kabi USA, LLC
  • 63323-596- Glucagon
    • 63323-596-13- 10 VIAL in 1 TRAY (63323-596-13) > 1 mL in 1 VIAL