Intravenous glucagon compared with intramuscular glucagon

StudyPopulationInterventionOutcomesResultsCommentsDesignEL
MacCuish et al, 197048799 insulin-treated patients with diabetes (and 1 patient on chlorpropamide) presenting to the diabetic or the accident and emergency department with hypoglycaemia established by blood glucose level.
20 out of 99 were 20 or under years old
Scotland
Patients were classified into three groups: 1. violent and/or very confused, 2. minimal response to maximal painful stimulation, 3. totally unresponsive to maximal painful stimulation
Randomly half were given treatment A. and the other half treatment B
If after 15 min patient was still comatose or unable to take oral glucose the treatment was repeated
If after 30 min patient still remained comatose 25 g glucose (50 ml 50% IV) administered and further protocol followed
Blood glucose estimations
Restoration of normal conscious level and average duration of hypoglycaemic coma
Severe adverse effects
Approximate duration of hypoglycaemia from witnesses
40 patients responded within 15 min of treatment of one injection of glucagon. 23 had been given glucagon by intramuscular and 18 by intravenous injection. No significant difference between the two treatments, RR = 0.84, 95% CI 0.61 to 1.17, p = 0.31
1 patient responded within 15 min of treatment with a second injection of glucagon
36 patients (who had not responded within 15 min of the second injection of glucagon) responded within 15 min of treatment with intravenous glucose
4 patients responded within 15 min of treatment with a second intravenous injection of glucose
19 patients did not respond to the second injection of glucose and were treated with mannitol infusions. Two patients died.
The effective treatment level that patients responded to was largely unrelated to the initial grading of level of consciousness. The level of consciousness was not always reflected in the admission blood glucose unless it was < 20 mg/dl
No description of how randomisation took place
No details of blinding of the study
Only rough estimation of coma duration was possible in several cases
Outcome of time to normal conscious level may not be important, can it be related to longterm outcomes?
Unknown the type of diabetes the patients were suffering from
RCTIb
Namba, 199348815 adult patients with type 1 diabetes
Mean age 51.9 ± 3.3 in the I.M group and 48.4 ± 4.1 years in the IV group
Japan
Patients were all relatively recentonset and admitted to the respective hospitals for the initial education for their diabetes and the establishment of control
Hypoglycaemia was induced through maintaining the patients in a fasting state and continuing their usual diabetic treatment
Patients were randomised to 2 treatments
  1. intramuscular biosynthetic glucagon (1 mg IM)
  2. intravenous biosynthetic glucagon (1 mg IV)
Plasma glucoseThe plasma glucose significantly increased in both IM and IV treatments. The increment of plasma glucose 20 min after treatment in the IM group was 74.7 ± 13.8 mg/dl and in the IV group 54.7 ± 8.7 mg/dl (p < 0.05), and after 40 min. treatment the plasma glucose level increment in the IM group was 108.8 ± 20.4 mg/dl and in the IV group 56.8 ± 10.2 mg/dl (p < 0.05)No description of how randomisation took place
No details of blinding of the study
Does induced hypoglycaemia act in the same way as accidental hypoglycaemia?
RCTIb

From: Evidence tables

Cover of Type 1 Diabetes
Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in Children and Young People.
NICE Clinical Guidelines, No. 15.2.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2004 Sep.
Copyright © 2004, National Collaborating Centre for Women’s and Children’s Health.

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