What is the role of glucagon therapy in the treatment of calcium channel blocker (CCB) toxicity?

Updated: Jan 04, 2021
  • Author: B Zane Horowitz, MD, FACMT; Chief Editor: Michael A Miller, MD  more...
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Answer

Glucagon promotes calcium entry into cells via stimulation of a receptor that is considered to be separate from adrenergic receptors. Note that the actions of glucagon oppose those of insulin, yet both have beneficial effects in treating CCB toxicity.

Glucagon is supplied as a lyophilized powder and must be reconstituted. Some manufacturers include an ampule of propylene glycol that can be used for single injections. However, the administration of large amounts of propylene glycol (the same diluent that is used for phenytoin) causes hypotension and dysrhythmias.

For this reason, glucagon infusions and repeat doses should be reconstituted in D5W to avoid giving large amounts of propylene glycol. If a positive clinical effect is noted after an initial IV bolus dose of 5-10 mg, an infusion can be continued at 5-10 mg/h. Note that such high-dose usage of glucagon exhausts a typical hospital pharmacy's supply within a few hours.

Administer glucagon (5-10 mg IV bolus up to 15 mg, followed by an infusion) after fluid resuscitation is performed for persistent hypotension. Since glucagon dilates the lower esophageal sphincter, vomiting and aspiration may occur; therefore, this treatment should only occur in an awake patient who can protect his or her own airway if vomiting occurs. Pretreatment with an antiemetic and large-bore bedside suction should be used. If an initial bolus of 5 mg of glucagon has no effect on blood pressure, it is reasonable to double the dose. The recommended infusion rate for adults is 5-10 mg/h. The recommended pediatric dose is 50 mcg/kg IV over 5 minutes, followed by an infusion at 0.07 mg/kg/h. [28, 29, 30, 31, 32, 33, 34, 35]


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