How to use mini-dose glucagon to increase low blood glucose levels during sick day management

Preparing mini-dose glucagon

1. Keep insulin syringes (30 or 50 unit) and alcohol wipes with your Glucagen Hypokit
2. Open the glucagon pack and flip the orange lid off the bottle
3. Remove protective rubber needle cover from glucagon syringe; this contains water
4. Inject all the water from the syringe into the glucagon bottle and mix gently
5. Remove glucagon syringe and discard
6. Use an insulin syringe to draw up glucagon dose
7. Measure by the units marked on the insulin syringe
8. Inject glucagon subcutaneously (under the skin) as you would insulin
9. After preparation, glucagon bottle can be stored in the fridge for up to 24 hours and re-used if necessary
10. Glucagon must not be used after 24 hours as it becomes unstable after this time
11. If re-using prepared glucagon, swab bottle top with an alcohol wipe and use a new syringe
12. Record your blood glucose level (BGL), response and treatment in your record book

Mild hypoglycaemia and sick day management

• Blood glucose level less than 4 mmol/L (hypoglycaemia) and unable to eat due to nausea and/or vomiting
• Use a mini-dose of glucagon to increase the BGL to 4-8mmol/L to prevent the development of more severe hypoglycaemia and avoid hospital admission

Treatment

1. Check BGL
2. Draw up 20 units of glucagon with an insulin syringe
3. Give the 20 units of glucagon subcutaneously as you would an insulin injection
4. Repeat BGL in 15 minutes. If BGL is still less than 4.0mmol/L repeat glucagon using 40 units
5. You can continue this cycle to keep BGL from 4-8mmol/L with mini doses of 20 units of glucagon every 2-3 hours
6. You may need to go to the emergency department or call an ambulance if there is no improvement after the second dose of glucagon
7. If vomiting or diarrhoea is present, try to maintain hydration with frequent sips of cordial or lemonade

Severe hypoglycaemia

Signs and symptoms

• Extremely irritable
• Semi-conscious
• Unconscious
• Fitting (convulsing)
• Mild hypoglycaemia can lead to severe
• hypoglycaemia if:
  • The initial treatment was delayed
  • The hypoglycaemia treatment was incomplete

Treatment
Keep calm; if a second person is present ask them to call an ambulance. If you are alone continue as below:

1. Place the person on their side and away from danger
2. Do not attempt to give anything by mouth
3. If able, check BGL
4. Draw up glucagon using glucagon syringe provided
5. Inject whole dose into upper outer quadrant of thigh or buttock
6. Call an ambulance stating it is a diabetic emergency
7. Once the BGL is above 4mmol/L the person will begin to wake
8. When awake give small sips of carbohydratecontaining liquid as tolerated, ideally 20g or 200ml of fruit juice or soft drink. Follow this with 40g of slower acting carbohydrate, e.g.two slices of bread (no insulin)
9. Check BGL every 15 minutes until able to eat carbohydrate

Recovery after a severe episode of hypoglycaemia

• Once BGL is stable between 4 and 8mmol/L, dose insulin for carbohydrate foods as usual
• Risk of hypoglycaemia is increased for 24 hours; avoid correcting a high BGL during this time
• Headache and fatigue are common after a severe episode of hypoglycaemia; rest and paracetamol are advised
• A repeat prescription for glucagon will be necessary to refill supplies if it has been used or it is out of date
• Consult your endocrinologist for advice following a severe hypoglycaemic event. This is extremely important

Caution

If hypoglycaemia is due to:

• alcohol consumption
• fasting during illness

Glucagon may not be effective in these situations due to insufficient glycogen stores. Seek urgent medical assistance.
Following a severe episode of hypoglycaemia always seek medical advice from your GP or the Queensland Diabetes and Endocrine Centre.

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