Glucagon for the treatment of symptomatic B-blocker overdose
Date First Published:
September 9, 2000
Last Updated:
May 15, 2003
Report by:
Russell Boyd, Consultant in Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
Angaj Ghosh, Manchester Royal Infirmary
Three-Part Question:
In [symptomatic significant beta-blocker overdose] is [intravenous glucagon] effective at [reversing the induced hypotension]?
Clinical Scenario:
A 25 year old patient presents to the emergency department 2 hours after taking a significant overdose of propanolol. She is bradycardic and hypotensive despite initial resuscitation with oxygen and IV fluids. An ECG shows a sinus bradycardia of 50 bpm. You have heard of treatment with IV glucagon but wonder if it has been of any proven benefit.
Search Strategy:
Medline 1966-02/03 using the OVID interface.
Search Details:
[exp glucagon OR glucagon.mp] AND [{exp adrenergic beta antagonist AND (exp poisoning OR exp overdose OR poisoning.mp OR intoxication.mp OR overdose.mp)} OR (beta blocker overdose.mp OR beta blocker poisoning.mp)]
Outcome:
Altogether 51 papers were found of which 6 were deemed relevant. No clinical trials were identified and all the papers available were case reports. Details of the papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Glucagon therapy for beta-blocker overdose. Peterson CD, Leeder JS, Sterner S. 1984, USA | 2 cases of mixed overdose including betablockers | Case report | Survival | Bolus of 12mg and 4mg used to reverse cardiogenic shock | Case report |
| Beta blocker overdose with propranolol and with atenolol. Weinstein RS, Cole S, Knaster HB et al. 1985, USA | 1 case of propanolol overdose | Case report | Survival | 80mg glucagon IV given over 18 hours to reverse cardiogenic shock | Case report |
| Beta blocker toxicity-the role of glucagon. Khan MI, Miller MT. 1985, South Africa | 1 case of propanolol overdose | Case report | Survival | Use of 20mg glucagon to reverse cardiogenic shock | Case report |
| Successful resuscitation and survival following massive overdose of metoprolol. Tai YT, Lo CW, Chow WH et al. 1990, Hong Kong | Single case of metoprolol overdose | Case report | Survival | 1mg of glucagon is claimed to have reversed cardiogenic shock | Case report |
| Severe oxprenolol poisoning: The importance of glucagon infusion. O'Mahony D, O'Leary P, Molloy MG. 1990, Eire | One patient following oxprenolol overdose |
Case report | Survival | 30mg bolus with 10mg/hr infusion of glucagon, successful resuscitation from beta blocker induced cardiogenic shock | Case report |
| Glucagon in the management of deliberate self-poisoning with propranolol. Mansell PI. 1990, Australia | Single mixed overdose including propanolol | Case report | Survival | Bolus of 4mg glucagon with an infusion of 10mg in 3 hours | Case report |
Author Commentary:
No clinical trials or even case controlled studies have been published. There is therefore only anecdotal evidence for the use of glucagon. The doses of glucagon are higher than the usual therapeutic doses given in hypoglycaemia and this is expensive. No reports of failure to respond to glucagon are found in the literature. This is probably attributable to reporting and publication bias. Further research is required.
Bottom Line:
There is not enough evidence currently available to support the use of glucagon in beta-blocker overdose.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Peterson CD, Leeder JS, Sterner S.. Glucagon therapy for beta-blocker overdose.
- Weinstein RS, Cole S, Knaster HB et al.. Beta blocker overdose with propranolol and with atenolol.
- Khan MI, Miller MT.. Beta blocker toxicity-the role of glucagon.
- Tai YT, Lo CW, Chow WH et al.. Successful resuscitation and survival following massive overdose of metoprolol.
- O'Mahony D, O'Leary P, Molloy MG.. Severe oxprenolol poisoning: The importance of glucagon infusion.
- Mansell PI.. Glucagon in the management of deliberate self-poisoning with propranolol.