Treatment of severe diabetic hypoglycemia with glucagon: an underutilized therapeutic approach

Figures & data

Figure 1 Distribution of self-reported number of episodes of severe hypoglycemia during the preceding year in 1049 unselected subjects with type 1 diabetes (light bars) and 209 patients with type 1 diabetes selected by criteria to mimic the characteristics of the DCCT cohort (dark bars).

Reprinted from Diabetes Metab Res Rev, 20, U Pedersen-Bjergaard, S Pramming, SR Heller, et al, Severe hypoglycaemia in 1076 adult patients with type 1 diabetes: influence of risk markers and selection, 479–486, copyright (2004), with permission from John Wiley & Sons.

Figure 2 Causes identified by patients for severe hypoglycemic events (as % of group). White bar = total of all countries (type 1, 319; type 2, 320); black bar = UK (type 1, 101; type 2, 100), grey bar = Germany (type 1, 94; type 2, 120), dotted bar = Spain (type 1, 124; type 2, 100).

Reprinted from J Med Econ, 12, M Lammert, M Hammer, BM Frier, Management of severe hypoglycaemia: cultural similarities, differences and resource consumption in three European countries, 269–280, copyright (2009), with permission from Informa Healthcare Communications.

Table 1 Causes of hypoglycemia

Cause	Example
Incorrect insulin administration	Insulin taken in excess or at the wrong time relative to food intake and/or physical activity; incorrect type of insulin taken
Insufficient exogenous carbohydrate	Delayed or missed meals or overnight fast
Decreased endogenous glucose production	Excess alcohol consumption
Increased utilization of carbohydrate/depletion of hepatic glycogen stores	Exercise or weight loss
Increased insulin sensitivity	During the night, exercise, weight loss
Delayed gastric emptying	Conditions such as gastroparesis
Decreased insulin clearance	Conditions such as progressive renal failure

Figure 3 Glycemic threshold levels for onset of acute hypoglycemia symptoms in nondiabetic subjects.

Reprinted from Hypoglycaemia and diabetes, Handbook of Diabetes, Oxford: Blackwell Publishing Ltd, 1st revision, G Williams, JC Pickup (editors), copyright (1998), with permission from John Wiley & Sons.

Table 2 Costs associated with severe hypoglycemia in three European countries (based on 2007 prices)

	Germany (€)	Spain (€)	UK (UK£)
HCP consultations
PCP office visit	7.40	15.10	32.42
PCP phone call	7.40	10.11	28.23
Diabetes specialist	19.40	52.35	112.93
Emergency HCP access costs
Ambulance	281.74	330.91	187.17
Emergency physician	318.86	65.52	72.15
Taxi transfer	21.48	10.55	10.00
Private car transfer	4.10	5.00	2.60
Emergency call (treatment guidance)	7.40	n/a	10.46
Hotline call (emergency)	7.40	n/a	10.46
Hospital costs
Emergency room	140.61	786.91	73.00
Intensive care unit	n/a	1264.61	1657.37
General ward	n/a	405.90	502.96
Hospitalization tariff	2517.00	n/a	612.76
Treatments
Sugar (estimate)	0.09	0.05	0.01
Sweet drinks (estimate)	0.50	0.45	0.35
Sweets, chocolate (estimate)	0.50	0.93	0.28
Oral glucose gel/paste	0.75	5.85	3.65
Glucagon (im)	27.74	21.40	11.52
Glucose (iv)	27.74	1.86	2.55
Training and other costs
Education	7.40	29.66	32.42
Dietary counseling	7.40	29.66	32.42
Hypoglycemia awareness training	7.40	29.66	32.42
Psychological counseling	7.40	29.66	32.42
Leaflets, books	2.21	2.21	1.50
Blood glucose test (patient self-test)	0.50	0.89	0.29
Salary per hour	20.74	10.67	11.92

Adapted from J Med Econ, 12, M Hammer, M Lammert, SM Mejias, et al, Costs of managing severe hypoglycaemia in three European countries, 281–290, copyright (2009), with permission from Informa Healthcare Communications.

Abbreviations: HCP, health care professional; PCP, primary care physician; n/a, not applicable; im, intramuscular; iv, intravenous.

Figure 4 Changes in blood glucose levels before and after the administration of 1 mg biosynthetic glucagon.

Reprinted from Diabetes Res Clin Pract, 19, M Namba, T Hanafusa, N Kono, et al, Clinical evaluation of biosynthetic glucagon treatment for recovery from hypoglycemia developed in diabetic patients, 133–138, copyright (1993), with permission from Elsevier.
Abbreviations: iv, intravenous; im, intramuscular.