With type 1 diabetes, much of the focus centers around insulin, and for good reason, since the pancreas produces little, if any, insulin with this condition. But there’s another hormone to know about, and that’s glucagon. Like insulin, glucagon is secreted by the pancreas. This hormone is sometimes called a “counterregulatory hormone” because it works opposite insulin to raise blood sugar levels in response to hypoglycemia (low blood sugar).
How glucagon works
In someone without type 1 diabetes, if blood sugar levels drop, the beta cells in the pancreas slow the release of insulin. At the same time, the alpha cells in the pancreas release more glucagon. Glucagon signals the liver to convert some of its stored glycogen into glucose. The glucose is then released from the liver into the bloodstream to bring blood sugar levels back up.
In a person with type 1 diabetes, the beta cells stop releasing insulin. And in some cases, a person can lose the ability to release glucagon in response to hypoglycemia. So, the liver doesn’t get the signal to release glucose; as a result, blood sugar can drop even further, leading to severe hypoglycemia.
Severe hypoglycemia is a serious situation that can lead to unconsciousness, seizures and coma. Treating severe hypoglycemia requires the assistance of someone else, and the treatment consists of administering glucagon or intravenous glucose. The “rule of 15,” such as eating glucose tablets or drinking juice, isn’t sufficient and isn’t viable (or safe) if someone has severe hypoglycemia.
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More about glucagon
As you learn about managing type 1 diabetes, make sure that your diabetes educator talks with you — and a family member, significant other or friend — about glucagon. Glucagon is available by prescription and up until recently, was only available as an injection.
Standard glucagon injections
Glucagon injections are given like an injection of insulin and can be given in the upper arm, thigh or buttocks, either under the skin or in the muscle. The typical dose for adults is 1 milligram (mg). Unlike insulin, traditional glucagon kits come as a powder and a liquid that have to be mixed right before giving the injection. This can be disconcerting for the person who needs to give the injection, because he or she may nervous and anxious about giving an injection, as well as helping someone who may be unconscious.
One of the side effects of glucagon is nausea and vomiting, so once the injection is given, the person should be placed on his or her side to prevent choking if they do vomit. Kathy Casper, RN, CDE, says, “Glucagon typically works within 10 to 15 minutes. If the person doesn’t respond, however, the person giving the injection should call 911 for immediate medical assistance.” Note: Many people prefer to call 911 before giving the glucagon injection.
In September 2019, the FDA approved the Gvoke HypoPen made by Xeris Pharmaceuticals. This device is an injection, but unlike the standard glucagon kits, Gvoke contains a room temperature liquid that is ready to use. It will be available in the U.S. starting in October 2019 as a prefilled syringe (Gvoke PFS), and then in 2020, the Gvoke HypoPen will be launched. Both the syringe and the pen will be available in two doses: 1 mg/0.2ml for adults and adolescents, and 0.5 mg/0.1 ml for children. Both the Gvoke syringe and pen will last up to two years at room temperature.
This ready-to-inject form of glucagon will be a less stressful way to administer glucagon, as no mixing of a powder and liquid is required. The cost of Gvoke is expected to be the same as the current glucagon kits, at a retail price of $280 per dose, before insurance. Xeris will also be launching a co-pay assistance program as well as a program for people who do not have insurance. For more information about Gvoke, visit the product website.
In July 2019, the FDA approved Baqsimi nasal powder, which is the first glucagon therapy that can be given without an injection. Manufactured by Lilly, Baqsimi has been approved to treat severe hypoglycemia in people with diabetes ages four and older.
Baqsimi comes in a single-use dispenser (similar to a nasal spray) and is delivered in a 3-mg dose as a puff in the nose rather than an injection. It can be used even if you are congested or have a cold. This form of glucagon is stored at room temperature, is stable for 18 months to 2 years, and, like Gvoke, is priced the same as current glucagon injection kits. In addition, for a limited time (until 12/31/19), people with commercial insurance may be able to pay as little as $0 for the first prescription of up to two Baqsimi devices; for refills, people may pay as little as $25 (this offer expires 12/31/2020). For more information, visit the Baqsimi website.
Important tips about glucagon
Ask your doctor or diabetes educator about glucagon and whether it’s right for you. Glucagon may not be safe to use for some people, such as people with an insulinoma (tumor of the pancreas) or a pheochromocytoma (tumor of the adrenal gland). Glucagon can also interact with some medications, such as beta-blockers, indomethacin and warfarin.
“Always check the expiration date of whatever form of glucagon you are using. It’s a good idea to write the expiration date on a sticky note and adhere that to the packaging to remind you about the expiration date,” advises Casper.
Consider bringing your spouse, significant other or family member to an appointment so that they can learn how to give you glucagon. You can also find education videos on YouTube and written instructions on the manufacturers’ websites.
Finally, if you are given glucagon for treating severe hypoglycemia, you are at risk for another occurrence of hypoglycemia. Once you are alert and able to swallow, make sure you drink a form of liquid carbohydrate, such as juice or regular soda to replenish glucose stores in your liver, and then eat a snack. And be diligent about checking your blood sugar frequently over the next few hours to detect hypo- or hyperglycemia (high blood sugar). Let your diabetes care team know that you received glucagon, as well as if you have repeated episodes of hypoglycemia so that your treatment plan can be re-evaluated and tweaked, as needed.