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Key points

  • We recommend to consult your poison centre with the use of this antidote
  • Consider only as adjunctive therapy for beta blocker intoxication. As first-line therapies, prioritize initiation of IV fluid repletion, vasopressors and high-dose insulin with dextrose. 
  • Considerations that limit the use of glucagon include: time required to prepare IV doses and frequent adverse effects (nausea, vomiting)
  • Higher doses are more likely to achieve maximum hemodynamic response compared with lower doses
  • Treatment Algorithms for Cardiovascular Toxicity:

+ Synonyms and other terms

Glucagenmd

+ Indications

Hypotension or bradycardia due to beta-blocker toxicity.

+ Dosage

+ Pediatric Dose

  • Loading Dose: 0.15 mg/kg (max 5mg) direct IV (1mg/min); can be repeated every 5 to 10 minutes until desired hemodynamic effect up to a maximum dose of 10mg.
  • Maintenance Dose: 0.05 to 0.1 mg/kg/h (max 5 to 10 mg/h) by continuous IV infusion

+ Adult Dose

  • Loading Dose: 5 mg direct IV over 3-5 min; can be repeated every 5 to 10 minutes until desired hemodynamic effect for a maximum of 2 doses (10mg).
  • Maintenance Dose: 5-10 mg/h, according to the total effective loading dose, by continuous IV infusion.

+ Renal Impairment

No data suggests that the dose should be modified for short-term use.

+ Hepatic Impairment

No data suggests that the dose should be modified for short-term use.

+ Hemodialysis Patient

No data suggests that the dose should be modified for short-term use.

+ Obese or Overweight Patient

No data suggests that the dose should be modified for short-term use.

+ Adverse effects

  • Nausea, vomiting (dose dependent)
  • Hyperglycemia (sometimes desirable with high dose insulin therapy)
  • Hypokalemia
  • Hypersensitivity reaction (rash, urticarial, rarely hypotension and anaphylactic shock)

     

+ Monitoring

  • Vital signs
  • Airway protection (vomiting)
  • Blood glucose, potassium
  • ECG : mainly heart rate and A-V conduction

+ End of treatment

  • Reassess the effect of glucagon within 1 hour of starting IV insulin infusion
  • When patient is hemodynamically stable, perform a gradual weaning of the infusion;
    • Decrease by 25% every 15 minutes with hemodynamic monitoring to stop the infusion in 1 hour
    • If BP and HR deteriorate, administer the initial effective loading dose, then resume the infusion at the same rate as before the reduction.

+ Special Notes on Administration

  • Intravenous Route (IV)
  • Direct IV
    • Administer the reconstituted solution with a final concentration of 1mg/mL direct IV at a rate of 1mg/min.
    • Glucagon should not be used at concentration greater than 1mg/mL.
  • Continuous IV infusion
    • Prepare only enough to last for 1 to 2 hours
      • Duration of adjunctive treatment with glucagon is generally short
    • Administer using a volumetric pump
    • Suggested preparations of glucagon 0.1mg/ml:
      • Preferred: 
        • 10 mg (10 ml) of glucagon in 90 ml of D5W. Final volume: 100 ml. Final concentration: 0.1mg/ml. 
      • Others:
        • 5 mg (5 ml) of glucagon in 15 ml of D5W. Final volume: 50 ml. Final concentration: 0.1mg/ml. 
        • 15 mg (15 ml) of glucagon in 135 ml of D5W. Final volume: 150 ml. Final concentration: 0.1mg/ml. 
        • 20 mg (20 ml) of glucagon in 180 ml of D5W. Final volume: 200 ml. Final concentration: 0.1mg/ml. 
        • 25 mg (25 ml) of glucagon in 225 ml of D5W. Final volume: 250 ml. Final concentration: 0.1mg/ml. 
        • 50 mg (50 ml) of glucagon in 450 ml of D5W. Final volume: 500 ml. Final concentration: 0.1mg/ml.
    • Note: Some glucagon preparations are intended for IM administration only according to the monograph (e.g. Glucagen), however, IV (off-label) administration is preferred and acceptable.
  • Subcutaneous Route (SC)
    • Possible alternative to the IV route
  • Intramuscular Route (IM)
    • Possible alternative to the IV route
  • Intraosseous Route (IO)
    • Possible alternative to the IV route
  • Reconstitution
    • Reconstitute each vial with 1.1 ml of the supplied diluent or with D5W, especially if continuous IV infusion.
    • Swirl the vial gently until the glucagon is completely dissolved and the solution is clear.
    • Final volume: 1ml
    • Final concentration: 1mg/ml
  • Compatibility
    • Partial list only. Consult the pharmacist on duty at your health care facility.
    • Compatible solutions: D5W
    • Y-site compatibility: no data
    • Y-site incompatibility: no data
  • Stability:
    • Glucagon (Lilly): Store unopened vials at room temperature (15 to 25 C)
    • Glucagen (Novo Nordisk): Store unopened vials between 2-8C
    • Protect vials from light and freezing
    • Glucagon is susceptible to gel aggregation formation at pH above 2 
    • Glucagon is unstable and should be used immediately after reconstitution. Discard any unused portion.

+ Available products

  • Glucagon Pd. Inj, 1mg per vial, Eli Lilly Canada Inc, DIN 02243297
    • Diluent: glycerine 1.2%
  • Glucagen Pd. Inj, 1mg per vial, Novo Nordisk Canada Inc, DIN 02333619
    • Diluent: ESI

+ Amount required to treat a person weighting 70kg during 24 hours

  • Stockage not  mandatory
  • If stockage is desired, an amount of 100 mg is considered sufficient

+ References

Joe-Anthony Rotella et al, Treatment for beta-blocker poisoning: a systematic review, Clinical Toxicology, 2020, 58:10, 943-983

Ottawa Parenteral Drug Therapy Manual 2010, Glucagon



Kaper M. Petersen et al, High-Dose Glucagon Has Hemodynamic Effects Regardless of Cardiac Beta-Adrenoceptor Blockade: A Randomized Clinical Trial, J Am Heart Assoc, 2020, 9:e016828



Solomon S. Steiner et al, Stabilized Glucagon Formulation for Bihormonal Pump Use, Journal of Diabetes Science and Technology, 2010, Volume 4, Issue 6, 1332-1334


Last updated : 2022-12-13