SB is a 58 yo F picking up a new prescription for a Glucagon Emergency Kit. Her primary care physician explained that she only needs to use it if her blood sugars get too low, but she’s confused about why she needs this medication since she already gets glucose tablets over the counter.

PMH: T2DM, HLD, HTN

Allergies: NKDA

Current Medication List:

Tresiba 15 units SQ at bedtime

Crestor 40 mg PO once daily

Glucophage 1000 mg PO twice daily

Trulicity 3 mg SQ once weekly

Altace 10 mg PO once daily

Vitals and lab results from recent clinic visit:

Wt: 88 kg

Ht: 5’5"

HR: 82 BPM

RR: 16 BPM

Temp: 98.6 F

BP: 124/76 mmHg

Na: 140 mEQ/L

FSBG: 120 mg/dL

A1C: 9.4%

Which of the following is appropriate counseling for the Glucagon Emergency Kit? Select all that apply. 

A. Glucagon Emergency Kit must be reconstituted with sterile water before administration.

B. Glucagon Emergency Kit also is available in a pre-filled syringe ready for administration.

C. Dosing for adults is 1 mg initially and may be repeated after 15 minutes if needed.

D. Wait at least 15 minutes after administration before giving any PO glucose.

E. The Glucagon Emergency Kit is recommended over PO glucose for every patient with a BG < 70 mg/dL.

Hypoglycemia is traditionally defined as a BG < 70 mg/dL, and patients may present with palpitations, sweating, and tremors or even confusion and unconsciousness in cases of severe hypoglycemia. Antidiabetic medications such as insulin and sulfonylureas can increase a patient’s risk of developing hypoglycemia. Pharmacists should be able to educate their patients on hypoglycemia warning signs and treatment options when their blood sugar is too low. Commonly the “Rule of 15” is used to treat hypoglycemia: if BG < 70 mg/dL, administer 15 grams of carbohydrates and recheck BG every 15 minutes. Continue this process until BG ≥ 70 mg/dL. If a patient is unconscious and unable to be administered oral or IV glucose, glucagon is an option to treat hypoglycemia.

Glucagon works by promoting glycogenolysis or the conversion of glycogen to glucose in the liver and is available in a variety of preparations allowing for intravenous, intramuscular, subcutaneous, or intranasal use. The Glucagon Emergency Kit specifically is able to be given in the upper arms, thighs, or buttocks. Pharmacists should be able to counsel on the preparation and administration of the various forms of glucagon available for patients. 

Answer choice A is correct. The Glucagon Emergency Kit comes as a bright orange container holding a syringe prefilled with sterile water and a vial containing dry powder. To prepare Glucagon Emergency Kit, the full syringe of sterile water should be injected into the dry powder vial and gently shaken without removing the syringe. Once the powder has dissolved completely, draw the solution into the syringe and remove it.

Answer choice B is incorrect. Although the Glucagon Emergency Kit requires reconstitution, there are other glucagon preparations that are available for immediate administration. Baqsimi is an intranasal glucagon option and GVOKE is a prefilled syringe of glucagon that may be given subcutaneously.

Answer choice C is correct. For adults and children ≥25 kg and ≥6 years old, the recommended dose is 1 mg (1 mL) or one full dose of the Glucagon Emergency Kit. For children <25 kg or <6 years old, the recommended dose is 0.5 mg (0.5 mL). If the patient does not wake up or show improvement in 15 minutes, another dose of Glucagon Emergency Kit may be given. Of note, a similar product GlucaGen Hypokit was discontinued in July 2024 in the United States. 

Answer choice D is incorrect. Once the patient is awake and able, PO glucose should be given as soon as possible. Some options with 15 g of carbohydrates that can be considered are glucose tabs, glucose gel, a tablespoon of honey, or a cup of orange juice.

Answer choice E is incorrect. For conscious patients with a BG < 70 mg/dL, a form of glucose should be given first to help raise the patient’s blood sugar. ADA Guidelines recommend glucagon in patients unable to take PO carbohydrates.

Medications: Glucagon Emergency Kit (Glucagon), Tresiba (Insulin Degludec), Crestor (Rosuvastatin), Glucophage (Metformin), Trulicity (Dulaglutide), Altace (Ramipril)

Naples Competencies Covered:

Area 2 - Identify Drug Characteristics

2.2 - Commercial availability; prescription or non-prescription status; brand, generic, or bio similar names; physical descriptions; or how supplied

Area 3 - Develop or Manage Treatment Plans

3.4 - Drug dosing or dosing adjustments; duration of therapy

3.5 - Drug route of administration, dosage forms, or delivery systems

Area 5 - Compound, Dispense, or Administer Drugs, or Manage Delivery Systems

5.4 - Equipment or delivery systems

5.5 - Instructions or techniques for drug administration