GLUCAGON: Overview and FAQ's

Glucagon, What is It?

Glucagon is a hormone that helps regulate the body’s blood sugar levels. It is also produced by the pancreas and works in the opposing function of insulin. While insulin helps lower blood sugar levels, glucagon increases them by signaling the liver to release stored glucose into the bloodstream.

Synthetic forms of glucagon, discussed here, are used as a medicine to treat severe hypoglycemia in people with diabetes. It is typically given to individuals with diabetes who are unable to bring up their blood sugar levels with oral carbohydrates or who have become unconscious (or experiencing seizures) due to hypoglycemia. Glucagon only works if there are adequate glycogen stores because glucagon causes the liver to break down and release glycogen into the bloodstream to raise blood sugar. If a person has had previous bouts of hypoglycemia and has not replaced their glycogen stores, glucagon as an emergency medicine will not be able to work.

Ideally, a person with diabetes will never need to use glucagon, but if required, it can be lifesaving.

Why is Glucagon Necessary?

Those familiar with diabetes, especially Type 1, know severe hypoglycemia is a dangerous condition that can occur when blood sugar levels drop too low, often due to taking too much insulin or not consuming enough food to match an insulin dose. It can cause a wide range of symptoms including confusion, shakiness, dizziness, seizures, even loss of consciousness. In the most severe cases, it is life-threatening.

Glucagon in either injectable or inhaled form is used to treat severe hypoglycemia. It works by signaling the liver to convert stored glycogen into glucose and release it into the bloodstream. This raises blood sugar levels and helps to alleviate the symptoms of hypoglycemia. Glucagon can raise blood glucose 100 mg/dl on average. Often glucagon needs to be administered by another person since the symptoms accompanying an extreme hypo can make it difficult or impossible for the person with diabetes to do it themselves.

It's incredibly important (we’ll say this again in case anyone missed it, INCREDIBLY IMPORTANT) for people with diabetes who are at risk of severe hypoglycemia to have a glucagon kit (or better yet, more than one) on hand in case of emergency. Kits typically contain a dose of glucagon and instructions for administration. People with diabetes and their caregivers should be trained on how to properly use glucagon in the event of an emergency before an emergency situation occurs. Ideally, this training is provided by healthcare providers at diagnosis but this isn’t always possible. There are many online resources to help people with diabetes learn how to use their glucagon kit (see below).

What Types of Glucagon Are Available?

There are currently two forms:

1. Injectable glucagon comes in a pre-filled syringe or an autoinjector and is administered via injection. It is usually given by a caregiver or trained individual, such as a family member or friend, in the event of an emergency. The injection is given either subcutaneously (under the skin) or intramuscularly (into a muscle). Injectable glucagon is generally safe and effective but may cause side effects such as nausea and vomiting. There are currently two companies that make injectable glucagon under the brand names Zegalogue and Gvoke.
2. Nasal Glucagon is a newer form of glucagon that was FDA approved in 2019. It comes in the form of a powder that is delivered through a nasal applicator. As an alternative to injectable glucagon and may be easier to use in emergency situations. Nasal glucagon is safe and effective but may also cause side effects such as nasal irritation and headache. One company currently makes inhaled glucagon under the brand name Baqsimi.

Current Glucagon Brands

• Baqsimi Nasal Glucagon from Lilly – 4 years and older 
• Gvoke Hypopen and prefilled syringe from Xeris – 2 years and older
• Zegalogue hypopen and prefilled syringe from Novo Nordisk  - 6 years of age and older

Glucagon Training Resources By Brand and Delivery Method

Baqsimi

Gvoke Hypopen

Gvoke Prefilled Syringe

Zegalogue Prefilled Syringe

Zegalogue Autoinjector

Which type of glucagon should I recommend?

Both are equally effective but there are a number of factors that go into selection. Price, insurance coverage, personal preference of person with diabetes for method of delivery (prefilled syringe, injector pen, or inhalation), ease of use (based on the individual and/or caregiver) and level of experience of the person who will most likely be needed to administer an emergency dose. 

When is the right time to give or take glucagon (what are the signs that glucagon is needed)?

This is a complex question because people’s experiences of low blood sugar differ by individual. It is important to help the person with diabetes know what the common symptoms of low blood sugar are and to guide them to educate those around them about these symptoms and the fact that signs of low blood sugar and when to treat with glucagon may vary by individual and over time. In addition, when one is experiencing hypoglycemia, the ability to reason is diminished. Educate the person with diabetes to know the early signs of low blood sugar, how to treat it, to carry a written copy of their Low Blood Sugar Care Plan with their diabetes supplies and to wear a medical identification bracelet, necklace or tattoo that identifies that they have diabetes.

Signs of low blood sugar include:

• Dizziness or shaking
• Feeling nauseous
• Fast heartbeat
• Hunger
• Irritability, restlessness, or anxiety
• Sweating
• Difficulty thinking
• Difficulty speaking
• Lack coordination
• Sleep disturbances
• Tingling lips, hands, feet or tongue
• Headache
• Tremors or unsteady movements
• Blurred vision
• Slurred speech

Please note that any of the above signs may indicate the need for glucagon in an individual so education is key.

And the signs that you need glucagon:

• Have tried correcting with food or drink and it isn't working
• Feel confused
• Are unable to eat or drink and feel as if you need help
• Are unable to swallow safely
• Feel like passing out
• Pass out or have a seizure

Specifically, how do you administer glucagon?

Below are links to the manufacturer’s instructions for use.

Baqsimi Nasal Glucagon 

Gvoke Glucagon Prefilled Syringe

Gvoke Glucagon Hypopen

Zegalogue Glucagon Prefilled Syringe

Zegalogue Glucagon Autoinjector

Following Administration

• After giving the dose, call for emergency medical help immediately.
• If the person is unconscious or seizing, turn them on their side.
• If conscious, encourage the person to eat as soon as possible. When they are able to safely swallow, give the person a fast-acting source of sugar, such as juice, glucose gel, honey, etc. Then encourage the person to eat a snack, such as crackers with cheese or peanut butter.
• If the person does not respond after 15 minutes, another dose may be given, if available.

What is the Shelf-Life and How Do I Store It?

Each Glucagon kit has an expiration date. Most kits usually last for 2 years after they are manufactured. Encourage the person to check the expiration date on their glucagon kit(s) on a regular schedule (for example before each visit with you) and request a new prescription if the kit is close to expiration.

Storage of the glucagon kit is an important piece of education. A glucagon kit should be kept in a location that is easy to access for the person and caregiver and be easily available in an emergency. Keeping one kit at home in the Emergency or Sick Day Kit is good practice. It is important that the person have a glucagon kit available with them when they are away from home with their emergency hypoglycemia supplies (glucose tabs, gel, or juice). 

Resources for information on hypoglycemia and sick day management

Sick day management adult

Sick day management child

Additional FAQs about glucagon

Can I use glucagon to treat mild hypoglycemia or just severe?

Currently glucagon is indicated for severe hypoglycemia only.

However, there is research being conduction on the use of glucagon in non-emergency situations for mild hypoglycemia. Mini-dosing might be recommended as part of sick day protocols or as a substitute for glucose. It is proposed that mini-doses may prevent the tendency to over-treat low blood sugars with too many carbs. In addition, glucagon is being studied for use in dual hormone pump therapy.

Here are two articles that look at mini-dose use of glucagon.

Nonaqueous, Mini-Dose Glucagon for Treatment of Mild Hypoglycemia in Adults With Type 1 Diabetes: A Dose-Seeking Study

Relationship between Optimum Mini-doses of Glucagon and Insulin Levels when Treating Mild Hypoglycaemia in Patients with Type 1 Diabetes - A Simulation Study

How much is Glucagon, does insurance cover it, are there any affordability programs to decrease costs?

The cost of Glucagon is dependent on an individual’s insurance. Savings cards are available from some manufacturers. 

Baqsimi Savings and Resources

Gvoke Savings and Support

What are the side effects of glucagon?

Common side effects of glucagon differ slightly depending on if using nasal or injectable and may include nausea and vomiting. These side effects typically resolve on their own within a few hours.

Can expired glucagon be used?

No, the individual should always check the expiration date on the glucagon kit and replace expired kits. Expired glucagon may not work as effectively, which can have dire consequences.

Can glucagon be used in children?

Yes, glucagon can be used in children. See dosing guidelines in their full prescribing information.

Baqsimi nasal glucagon is approved for individuals 4 years and older

Gvoke is approved for individuals 2 years and older

Zegalogue is approved for individuals 6 years and older

Can I use glucagon if I am pregnant or breastfeeding?

Glucagon has not been studied extensively in pregnant or breastfeeding women.  

Does Alcohol Affect Glucagon? How?

Yes! The liver will not be able to release glycogen if it is busy detoxifying alcohol. The liver will choose detoxifying over releasing glycogen even with the administration of glucagon. Intravenous glucose administration by a medical professional is required.

What should the patient and caregiver be concerned about after administering glucagon?

• Calling 911 to get to a hospital even if the person states that they feel ok. They need to be evaluated by a physician and treated medically.
• Administering a second glucagon injection if it is available and the first one did not work.
• Vomiting may occur after administration. The person should not be left on their back in order to prevent choking.
• The need to consume fast acting carbohydrates if they have the ability to swallow.
• The importance of fefeeding with carbohydrates, protein and fat in order to get glycogen stores back up to a healthy level.

As Follow-up After Emergency Has Been Resolved 

• Encourage the person with diabetes to inform their healthcare provider to learn from this case of hypoglycemia – hypoglycemia does happen despite a person’s best efforts. Taking the time to understand why it happened may prevent it from happening again and if there is hypoglycemia unawareness, a plan (including technology like a Continuous Glucose Monitor) will help prevent it from happening in the future and decrease anxiety over it occurring again.
• Provide the person with diabetes with a referral to a therapist to talk about the experience . If you do not know any therapists on the person’s insurance, this resource can help you find providers who are familiar with diabetes and the stressors that go along with living life as a person with diabetes.
• Go over their Low Blood Sugar Care Plan, encourage them to identify what worked for them and what needs revision (See this resource for an example).

Glucagon At-A Glance Comparison Chart

ADCES Resources:

Managing low blood sugar in Children

• In English
• In Spanish

Managing low blood sugar in Adults

• In English
• In Spanish

Low Blood Sugar Road Map This resource has:

• Definitions, education, and information on low blood glucose and glucagon
• Logs to record low blood sugar incidents with details to help track and understand,
• A Low Blood Sugar Care Plan and Identification  that people with diabetes can carry on themselves to inform others what to do if they are experiencing a hypoglycemic event
• List of common symptoms of hypoglycemia

Applying The ICC Framework