Glucagon Underutilized for Hypoglycemia Treatment

Miriam E Tucker

December 27, 2017

Glucagon is underused for treating severe hypoglycemia in both emergency and outpatient settings, new research suggests.

Findings from an analysis of data on glucagon administration by emergency personnel and glucagon prescribing under Medicare were published online December 26 in Annals of Internal Medicine by Peter A Kahn, MD, Yale School of Medicine, New Haven, Connecticut, and colleagues.

Patients with diabetes treated with insulin or sulfonylureas are at increased risk for hypoglycemia, which results in more than 100,000 US emergency department visits annually. Glucagon could reduce the number and severity of those episodes, and family members use it routinely on their loved ones.

Yet in most states only paramedics — and not basic emergency medical technicians (EMTs) — are allowed to carry and administer glucagon.

Since there are only about 61,121 paramedics nationwide compared with 198,200 EMTs, three of four dispatched responders may be unable to treat a patient with glucagon, Dr Kahn and colleagues explain. 

"All emergency personnel should have access to glucagon, along with training to safely administer this agent to minimize unintended treatment accidents. Ensuring this access represents an important opportunity to reduce morbidity, mortality, and health care costs," they write.

And diabetes specialists should work with emergency medical personnel to design curricula for safe and effective use of glucagon nationwide, they advise.

Underuse, Miscoding Among the Problems

In the National Emergency Medical Services (EMS) information system, glucagon was administered in 89,263 emergency cases between 2013 and 2015, but only 44.7% had been correctly coded as a "diabetic problem."

Patients experienced adverse effects from glucagon in 3944 of the events, most of them were not serious and typically involved nausea, the authors note.

The mean EMS response time from the initial call to glucagon administration was 15.34 minutes.

"Such a delay, coupled with policies preventing EMT-basic providers from administering glucagon may increase patients' risk for neurologic sequelae, death, or both," Dr Kahn and colleagues stress.

The cost of inpatient admissions for hypoglycemia averaged $18,961, and emergency department visits, $1487 (both adjusted for inflation). 

The data did not include personnel information, but the lack of nationwide protocols permitting EMTs to carry and use glucagon — or even check blood glucose levels in some states — probably impedes care, the authors say.

And they add, "These restrictions are even more surprising given that glucagon is routinely administered by family members and the adverse effects experienced by those receiving this agent were not serious."

Outpatient Glucagon Use Also Low

Dr Kahn and colleagues also analyzed data from the Centers for Medicare & Medicaid Service data warehouse for 2014. The total cost to Medicare Part D for 23,423 glucagon prescriptions was $5,044,593 (adjusted for inflation) with an average cost of $212 per prescription.

Glucagon prescriptions were written for only 0.2% of approximately 11,600,000 Medicare beneficiaries with diabetes in 2014.  

Patients who filled glucagon prescriptions had fewer hypoglycemia-related emergency department visits, suggesting that wider use could reduce prehospital hypoglycemic complications, the authors say.

Dr Kahn reported no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

Ann Intern Med. Published online December 26, 2017. Abstract

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