In this episode, I’ll discuss why glucagon is not recommended in the calcium channel blocker poisoning guidelines.
Critical Care Medicine has published in 2017 Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. These guidelines list the following first line therapies prioritized based on desired effect:
1. IV calcium
2. High-dose insulin therapy
3. Norepinephrine and/or epinephrine
The guideline authors make additional recommendations for cardiogenic shock, refractory patients, and peri-arrest patients including dobutamine, atropin, lipid emulsion, pacemaker therapy, and VA-ECMO.
However noticeably absent from these guidelines is any mention of glucagon in the main article.
Glucagon is often referenced as a possible treatment for calcium channel blocker overdose because it can cause increases in heart rate, blood pressure, and cardiac contractility, without regard to calcium channels being blocked. These effects occur because glucagon directly increases cyclic AMP.
The only mention of glucagon occurs in the appendix for the guidelines where the authors give the following explanation:
The workgroup suggests not to use glucagon because case series reported variable effects. Vomiting and hyperglycemia have been reported in several case reports, and more effective interventions for the treatment of CCB poisoning are available.
The more effective intervention that the guideline authors are referring to is high-dose insulin therapy. This therapy is growing in popularity as it has demonstrated consistent effects and is feasible to implement.
Clinicians should note that there is not a corresponding expert guideline for beta-blocker overdose, and although high-dose insulin therapy is effective for this indication as well, many publications still recommend giving glucagon for beta-blocker overdoses.
Members of my Hospital Pharmacy Academy have access to practical training on the use of high-dose insulin therapy, as well as clinical pearls related to using glucagon, all from a pharmacist’s point of view. This is in addition to hundreds of other resources to help in your practice. The Hospital Pharmacy Academy is my online membership site that teaches pharmacists practical critical care and hospital pharmacy skills you can apply at the bedside so that you can become confident in your ability to save lives and improve patient outcomes. To get immediate access, go to pharmacyjoe.com/academy.
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