Hypoglycemia and Glucagon Utilization in Insulin-Treated Diabetic Patients

Abstract

Background First choice of therapy for severe hypoglycemia outside hospital environment is glucagon injection, an undertaught and underused remedy. Aim of this study was to investigate knowledge about glucagon therapy, possession rate and usage rate in insulin-treated diabetic patients, with special emphasis on history of hypoglycemia and severe hypoglycemia episodes. Methods In this cross-sectional study, 300 insulin-treated diabetic patients (146 males and 154 females, mean age 61.1±16.4 years) were recruited from comprehensive Diabetes Center in Croatia. Specialized self-administered, 13-item questionnaire regarding glucagon therapy and history of hypoglycemia was obtained from each patient, as well as data collected from medical history documentation. Results Experience of hypoglycemic episode was reported by 233 (77.7%), and severe hypoglycemia by 73 (24.3%) patients. Participants with experience of hypoglycemia have significantly longer diabetes duration (17.2±11.2 vs. 11.9±8.5 years, P<0.001) and lower BMI values (26.38±3.97 vs. 31.11±7.17 kg/m2, P<0.001). Knowledge about glucagon therapy had 55.3% patients, 44.7% obtained it from the pharmacy, while glucagon was used in 35.6% cases of severe hypoglycemia. Glucagon knowledge was better in patients that attended at least one diabetes lecture (P=0.038), while educational level showed no statistical significance (P=0.286). Main significant positive predictor of glucagon knowledge was history of severe hypoglycemia (OR 4.71, 95% CI 1.38 – 16.02, P=0.013). Conclusions Glucagon therapy was underused in treating severe hypoglycemia. It is highly important to emphasize value of quality education as one of the fundamentals of good diabetes management.

Use of glucagon in severe hypoglycemia is scarce in most countries, and has not been expanded by new ready-to-use glucagons

“…To our knowledge, this is the first analysis of use of glucagon for SH in several countries/ regions around the world. Use of traditional glucagon kits is low, as reported in previous studies [10][11][12], and the new finding is that the use is low in the totality of countries examined, so that a significant correlation was found between persons with diabetes or type 1 diabetes and units of glucagon sold each year. Units sold per person from 2014 to 2021 were 0.407 ± 0.661 to 0.507 ± 0.774 (Mean ± SD) in 2021, that means that < 50% of persons with diabetes had glucagon available, and probably even fewer persons were treated with glucagon for SH.…”

“…We know that old formulations remain unpopular because of problems connected with the preparation and administration of glucagon [9][10][11][12], and the general hope was that the availability of new ready-to-use glucagon drugs might expand its use. Units sold were always approximately tenfold greater in the countries/regions where new ready-to-use glucagon drugs (Baqsimi, Gvoke, Zelagogue) were available in 2019-2021 than in remaining countries/regions; however, this did not mean a more frequent use of glucagon, as reflected by the significant correlation between persons with type 1 diabetes and units of glucagon sold, independently from approval of new ready-to-use drugs.…”

“…Therefore, correct administration of glucagon requires reconstitution of a solution, and this, especially under stress or emergency situations, is difficult to obtain for untrained patients or care-givers [9]. This is one of the reasons why, compared with the expectations, glucagon injection is under-utilized in some countries [10][11][12]. In 1997, a survey showed that patients would have been enthusiastic on the idea that easily administered formulations would substantially expand the use of glucagon to prevent or to treat hypos, but a survey showed that 75% adult patients with diabetes did not carry a glucagon emergency kit [9].…”

Usability of Nasal Glucagon Device: Partially Randomized Caregiver and Third-Party User Experience Trial with Simulated Administration at a Japanese Site

“…The possession rate for glucagon among patients with T1D in Japan is reportedly very low (15.9%), mostly because patients do not think they will need glucagon, but also because of reluctance by family members to inject [9]. Higher glucagon possession rates have been reported in Australia (92%) [8], Israel (60%) [17], Croatia (45%) [18], and the USA (49%) [19]; this difference may reflect the lack of a glucagon kit in Japan, the older age of patients in this study (most other studies were of pediatric patients), or cultural factors. Because the NG device is ready to use and is less intimidating than using a syringe and needle for IMG injection, availability of the NG device may help increase the number of patients who keep glucagon on hand.…”

Update on the management of diabetes in long-term care facilities

“…In addition, many physicians and patients with diabetes fail to recognize the importance of glucagon injection. Studies from Japan and Croatia report the underuse of glucagon for both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) 96 99. In Canada, the percentage of glucagon administration to patients being transferred to the hospital for hypoglycemia was only 40% prehospitalization and less than 1% in the emergency department.…”