Strategies and Options for the Management of Hypoglycemic Emergencies - Episode 10

Selecting or Switching Formulations of Glucagon

July 10, 2021
Peter Salgo, MD, Columbia University Irving Medical Center

Columbia University College of Physicians and Surgeons

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Elaine Apperson, MD, University of South Carolina School of Medicine

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Davida Kruger, MSN, APN-BC, BC-ADM, Henry Ford Health System

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Anne Peters, MD, Keck School of Medicine of the University of Southern California

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Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM, Touro University California College of Osteopathic Medicine

Key opinion leaders in endocrinology provide an overview of factors to consider when selecting or switching intranasal and injectable glucagon including ease of administration and patient preference.

Peter Salgo, MD: Let’s talk about patient factors. We alluded to it, but let’s make it a bit more concrete. What are the patient factors that you consider when you’re talking about the injectable treatment vs the nasal spray? Let’s take the red kit out for now because I’m getting a sense none of you guys really likes that very much, but it was all you had for a while. Let’s look at these 2 new therapies: the injectable and the intranasal. Are there some patients who are better off with 1 rather than the other? If they like 1 or the other, can you switch from 1 class of therapy to another? Elaine?

Elaine Apperson, MD: Absolutely. You could definitely switch, but we’re not really talking about a patient but who’s going to be administering it. I don’t know that patient factors really matter as much as looking around and seeing who might be attending to that person is: spouse, nursing aide, coach, roommate, or teacher. 

Peter Salgo, MD: I shouldn’t have said patients. I should have said sociologic factors because that’s the whole environment, right? It’s the whole ecosphere.

Elaine Apperson, MD: What Davida said was also really important: insurance coverage, at the end of the day, is going to make a difference too. It makes a big difference for all of us. Look, we don’t get too picky around basal and bolus insulin. We usually just go by what the insurance tells us to prescribe. That’s often the way medicine works these days. We say, “We are going to use growth hormone, so we must look at the insurance. We’re going to use this or that or the other.” We are going to look at the insurance first. It’s part of being an endocrinologist. It’s really all the same in the end. It’s the brand we use or what the insurance tells us to use. Unfortunately, that extends to glucagon products. Luckily, as Davida also mentioned, usually 1 or the other is covered.

Peter Salgo, MD: Is it fair to say, from what I’m hearing, that it’s in the “do not care” mode? They both work; they’re both efficacious. If insurance covers 1, just buy that 1. If insurance covers the other 1, buy that?

Elaine Apperson, MD: Personally, the form factor is important: the prefilled syringe and the pen-like device is more familiar to patients with diabetes than the intranasal and injection. I have children who haven’t received the full dose of the intranasal glucagon when they’re seizing because they’re hard to control.

Peter Salgo, MD: In other words, it’s what you pointed out before. If a kid is writhing or moving around, it’s tough to put something in that kid’s nose and get the whole dose in there.

Elaine Apperson, MD: You put it in, and they suddenly jerk, and you don’t know if they’ve got it and you’ve already used 1 Baqsimi a month ago. Then what do you do?

Peter Salgo, MD: I hear what you’re saying. You like the SC [subcutaneous] version better.

Elaine Apperson, MD: I do.

Peter Salgo, MD: Can we take a vote? Who likes what? Why don’t we go around the horn a little. Davida, what do you like?

Davida Kruger, MSN, APN-BC, BC-ADM: I agree. I tend to like the prefilled forms of this, only because it reminds people of an EpiPen. It’s easier to find a body part to be able to put it in vs having to get it in the nose.

Peter Salgo, MD: I’m sorry, you just reminded me—pick a body part, any body part. But it makes sense—

Elaine Apperson, MD: I heard that it hurts, that the intranasal spray really hurts. One family used it a little prematurely, and the patient wasn’t truly unresponsive yet, so they said it was the most painful.

Peter Salgo, MD: Really? We didn’t discuss this—the intranasal hurts?

Elaine Apperson, MD: Well, anecdotally.

Davida Kruger, MSN, APN-BC, BC-ADM: I haven’t heard that, but most of my patients are unconscious when I get it, so I’m not sure that counts.

Elaine Apperson, MD: This poor child wasn’t quite unconscious yet, and it hurt.

Davida Kruger, MSN, APN-BC, BC-ADM: Patients and family members are just grateful for using either of those as opposed to the panic when they open the red box and say, “Now what do I do?” That’s when the 911 call usually happens.

Peter Salgo, MD: Anne, what do you vote for?

Anne Peters, MD: My patients’ caregivers or family members generally prefer the intranasal glucagon because they’re used to putting nasal spray in because their sinuses are bad or whatever. That’s something they relate to. I don’t have that many family members who are used to giving epinephrine, so they tend to prefer the intranasal method. But it’s not about me; it’s about them.

Davida Kruger, MSN, APN-BC, BC-ADM: Yeah.

Anne Peters, MD: I offer it, and I have samples. I ask, “Which 1 do you want?” We also talk about insurance coverage, but if the world were neutral, it’s simply what a family member wants.

Davida Kruger, MSN, APN-BC, BC-ADM: Absolutely.

Anne Peters, MD: I’ve shown people both, and they take whatever they want because it’s about using it. I’ve had patients give it to themselves—the intranasal stuff—and they say it feels like a bullet to the brain. You don’t want a conscious person using glucagon intranasally because it’s a very strong drug and a very strong push-up. But it’s working. It’s really spraying that stuff in the back of your nose. Don’t use it for conscious patients. That’s not a good thing.

Peter Salgo, MD: My thought is that after everybody has had a year of having tongs put up their noses for COVID-19 tests, we could all be desensitized to this. Jay, what do you think?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: I’m agnostic. I feel like it’s whatever you’re going to fill, whatever the family is comfortable giving—that’s what I’m going to write. Because I treat both adults and kids, it’s all over the map in terms of the response. I need them to have confidence that they can give it, that they can afford it, and that they will fill it. I’ll use any of them because when used properly, they can all work.

Peter Salgo, MD: I want to thank all of you at home for watching this HCPLive® Peer Exchange. If you enjoyed the content, I want you to subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your in-box.

Transcript Edited for Clarity

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