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Three Part Question

In [insulin-dependent diabetic adults with accidental hypoglycaemia] does [intravenous glucose or intramuscular glucagon] provide [faster, more reliable restoration of normoglycaemia]?

Clinical Scenario

An insulin dependent diabetic adult is brought into the Emergency Department uncooperative and acutely confused. A blood glucose stick test confirms hypoglycaemia. You wonder whether parenteral glucose or glucagon is the drug of first choice.

Search Strategy

Medline 1966-03/00 using the OVID interface.
[({exp glucose OR glucose.mp OR dextrose.mp} AND {IV.mp OR exp injections, intravenous OR intravenous.mp}) AND {exp glucagon OR glucagon.mp} AND {exp hypoglycemia OR hypoglycaemia.mp OR hypoglycemia.mp}] LIMIT to human AND english.

Search Outcome

166 papers found of which 162 irrelevant or of insufficient quality for inclusion. The four remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Collier A et al, 1987, UK	52 consecutive insulin dependent diabetic patients with hypoglycaemic coma. IV glucagon 1mg vs IV glucose 25g	Controlled clinical trial	Recovery time to	6.5 min vs 4 min	Not randomised. Not blinded.
Patrick AW et al, 1990, UK	29 consecutive insulin dependent diabetic patients with hypoglycaemic coma. IM glucagon 1mg vs IV glucose 25g	PRCT	Failures	2 glucagon failures	Not blinded. Small numbers.
			Recovery time to	9 min vs 3 min
Hvidberg A et al, 1992, Denmark	10 healthy non-diabetic subjects with experimental insulin induced hypoglycaemia. IM glucagon 1mg vs IV glucose 25g	Controlled experiment	Time to normoglycaemia	No significant difference	Non-diabetic subjects
Howell MA and Guly HR, 1997 UK	28 insulin dependent diabetic patients with hypoglycaemic coma in the prehospital environment. IM glucagon 1mg vs IV glucose 25g	Controlled clinical trial	Time to Glasgow Coma Scale score of 15	Significantly longer after glucagon	Block randomised. Not blinded. Small numbers.
Carstens S et al, 1998, Denmark	14 IDDM patients sequentially seen by a mobile ICU presenting with blood sugar< 3mmol	Randomised controlled trial of IV dextrose 50mls 50% versus IM glucagon 1mg	Time from treatment initiation to a full GCS 15 recovery	Recovery time for IV glucose mean 2.5 mins and for IM glucagon13.1 mins	Only 14 of 64 episodes actually attended were randomised. Not effectively blinded

Comment(s)

Although no high quality evidence exists in this area it is clear that IV glucose works faster than IM glucagon once the treatment has been given. The time to establish access has not, however, been accounted for. Glucagon "failures" have been reported.

Clinical Bottom Line

IV glucose is the most reliable treatment for accidental hypoglycaemia. Once venous access is established it is also has the fastest effect.

References

1. Collier A, Steedman DJ, Patrick AW et al. Comparison of intravenous glucagon and dextrose in treatment of severe hypoglycemia in an Accident and Emergency department. Diabetes Care 1987;10:712-5.
2. Patrick AW, Collier A, Hepburn DA et al. Comparison of intramuscular glucagon and intravenous dextrose in the treatment of hypoglycaemic coma in an Accident and Emergency department. Arch Emerg Med 1990;7:73-7.
3. Hvidberg A, Jorgensen S, Hilsted J. The effect of genetically engineered glucagon on glucose recovery after hypoglycaemia in man Br J Clin Pharmacol 1992;34:547-50.
4. Howell MA, Guly HR. A comparison of glucagon and glucose in prehospital hypoglycaemia J Accid Emerg Med 1997;14:30-2.
5. Carstens S et al, TBC