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Diabetes mellitus type 1 - management of persistent hypoglycaemia using mini dose glucagon

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 glucagon kit  insulin syringe
 GlucaGen® Hypokit Insulin syringe 30unit 

Glucagon hydrochloride - 1mg/ml

Mini-dose Glucagon rescue

Use of mini-dose glucagon can be effective when a child or young person with type 1 diabetes mellitus is unable to maintain a blood glucose level above 4mmol/L for any of the following potential reasons:

  • Inability to tolerate oral carbohydrate. (e.g. nausea and vomiting associated with inter-current illness)
  • Persistent hypoglycaemia despite repeated treatment or on the presumption of impending hypoglycaemia (for example insulin dose error; prolonged high intensity activity)

Glucagon

Glucagon is a hyperglycaemic agent that mobilises liver glycogen into glucose which is then released into the blood. Glucagon will not be effective in children whose liver glycogen is depleted (e.g. fasting; alcohol induced hypoglycaemia).

Mini-dose glucagon 10 µg / unit subcutaneously via insulin syringe
Minimum dose 2units (20 µg)
Maximum dose 15units (150 µg)

It is important to remember that:

  • Mini-dose glucagon can only be administered via an insulin syringe
  • Onset of effect occurs within 5-15 minutes after an injection
  • Effect on capillary blood glucose is usually seen within 10 minutes
  • Duration of action is in the range of 5-20 minutes depending on the dose

Evidence for mini-dose glucagon rescue

Haymond & Schreiner (2001) describe the effectiveness of small doses of subcutaneous glucagon in children with type 1 diabetes mellitus during periods of gastroenteritis or poor oral intake because of mild or impending hypoglycaemia. The report demonstrates evidence that small doses of subcutaneous glucagon can result in increased blood glucose levels within 30 minutes of its administration, with duration of ~60 min. In no instance is acute nausea or vomiting reported.

Stability

No studies are available regarding the potency of reconstituted glucagon over time. There are also no available studies relating to the clinical efficacy of repeated doses. Haymond (2001) presents findings with two distinct studies indicating a positive therapeutic effect of subcutaneous glucagon in doses of 20 - 150 µg, after sequential administrations (minimum of 2 in sequence), and over a 25-h period of time.

Indication for use

Consensus opinion is that the use of mini-dose glucagon according to a strict treatment algorithm in association with intensive home glucose monitoring and frequent phone contact with a clinician or diabetes nurse specialist can safely and effectively manage both mild hypoglycaemia and impending hypoglycaemia in the community setting (Brink et al, 2014; Hammond et al, 2001; Hartley, Thomsett & Cotterill, 2006).

The International Society for Pediatric and Adolescent Diabetes (ISPAD) advises the use of mini-dose glucagon for the management of mild hypoglycemia (<3.5-4 mmol/l) when nausea and food refusal are prominent (Brink et al, 2014).

Clinical management

Signs & Symptoms

  • Blood glucose <4 mmol/L with food refusal OR inability to tolerate carbohydrate due to nausea or vomiting
  • Blood glucose <4 mmol/L for a prolonged period of time despite repeated oral treatment using fast acting carbohydrate
  • Self-reported probable impending hypoglycaemia due to specific event (i.e.: insulin error, sports day with no preceding insulin reduction)

Minidose Glucagon Treatment Algorithm (Chung & Hammond, 2015)

treatment algorithm

Following administration of mini-dose glucagon

Once reconstituted, glucagon can be refrigerated for up to 24hours.

Sequential mini-dose glucagon can be given to a maximum of 5 doses however after 2 sequential doses consider hospitalisation for IV dextrose therapy.

Information for Families

See the Starship Diabetes Team education series for families

References

  1. Brink, S., Joel, D., Laffel, L., Lee, W.W.R., Olsen, B., Phelan, H. & Hanas, R. (2014). Sick day management in children and adolescents with diabetes. Pediatric Diabetes 15 (Suppl. 20): 193-202.
  2. Chung, S & Hammond, M. (2015) Minimizing morbidity of hypoglycaemia in diabetes: A review of mini-dose glucagon. Journal of Diabetes Science and Technology 9(1), 44-51.
  3. Haymond, M.W. (1996). Glycemic rescue using mini-dose glucagon in managing gastroenteritis in children with IDDM (Abstract). Diabetes 45 (Suppl. 2), 264A.
  4. Hammond, M.W., Schreiner, B. (2001). Mini-dose glucagon rescue for hypoglycaemia in children with type 1 diabetes. Diabetes Care, Volume 24(4), 643-645.
  5. Hartley, M., Thomsett, M.J., Cotterill, A.M. (2006). Mini-dose glucagon rescue for mild hypoglycaemia in children with type 1 diabetes: the Brisbane experience. J Paediatric Child Health 42(3), 108-111.

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Document Control

  • Date last published: 28 June 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Endocrinology
  • Author(s): Rosalie Hornung, Craig Jefferies, Paul Hofman, Fran Mouat
  • Owner: Rosalie Hornung
  • Editor: Greg Williams
  • Review frequency: 2 years

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