Selecting or Switching Formulations of Glucagon – MD Magazine

Peter Salgo, MD: Lets talk about patient factors. We alluded to it, but lets make it a bit more concrete. What are the patient factors that you consider when youre talking about the injectable treatment vs the nasal spray? Lets take the red kit out for now because Im getting a sense none of you guys really likes that very much, but it was all you had for a while. Lets look at these 2 new therapies: the injectable and the intranasal. Are there some patients who are better off with 1 rather than the other? If they like 1 or the other, can you switch from 1 class of therapy to another? Elaine?

Elaine Apperson, MD: Absolutely. You could definitely switch, but were not really talking about a patient but whos going to be administering it. I dont know that patient factors really matter as much as looking around and seeing who might be attending to that person is: spouse, nursing aide, coach, roommate, or teacher.

Peter Salgo, MD: I shouldnt have said patients. I should have said sociologic factors because thats the whole environment, right? Its the whole ecosphere.

Elaine Apperson, MD: What Davida said was also really important: insurance coverage, at the end of the day, is going to make a difference too. It makes a big difference for all of us. Look, we dont get too picky around basal and bolus insulin. We usually just go by what the insurance tells us to prescribe. Thats often the way medicine works these days. We say, We are going to use growth hormone, so we must look at the insurance. Were going to use this or that or the other. We are going to look at the insurance first. Its part of being an endocrinologist. Its really all the same in the end. Its the brand we use or what the insurance tells us to use. Unfortunately, that extends to glucagon products. Luckily, as Davida also mentioned, usually 1 or the other is covered.

Peter Salgo, MD: Is it fair to say, from what Im hearing, that its in the do not care mode? They both work; theyre both efficacious. If insurance covers 1, just buy that 1. If insurance covers the other 1, buy that?

Elaine Apperson, MD: Personally, the form factor is important: the prefilled syringe and the pen-like device is more familiar to patients with diabetes than the intranasal and injection. I have children who havent received the full dose of the intranasal glucagon when theyre seizing because theyre hard to control.

Peter Salgo, MD: In other words, its what you pointed out before. If a kid is writhing or moving around, its tough to put something in that kids nose and get the whole dose in there.

Elaine Apperson, MD: You put it in, and they suddenly jerk, and you dont know if theyve got it and youve already used 1 Baqsimi a month ago. Then what do you do?

Peter Salgo, MD: I hear what youre saying. You like the SC [subcutaneous] version better.

Elaine Apperson, MD: I do.

Peter Salgo, MD: Can we take a vote? Who likes what? Why dont we go around the horn a little. Davida, what do you like?

Davida Kruger, MSN, APN-BC, BC-ADM: I agree. I tend to like the prefilled forms of this, only because it reminds people of an EpiPen. Its easier to find a body part to be able to put it in vs having to get it in the nose.

Peter Salgo, MD: Im sorry, you just reminded mepick a body part, any body part. But it makes sense

Elaine Apperson, MD: I heard that it hurts, that the intranasal spray really hurts. One family used it a little prematurely, and the patient wasnt truly unresponsive yet, so they said it was the most painful.

Peter Salgo, MD: Really? We didnt discuss thisthe intranasal hurts?

Elaine Apperson, MD: Well, anecdotally.

Davida Kruger, MSN, APN-BC, BC-ADM: I havent heard that, but most of my patients are unconscious when I get it, so Im not sure that counts.

Elaine Apperson, MD: This poor child wasnt quite unconscious yet, and it hurt.

Davida Kruger, MSN, APN-BC, BC-ADM: Patients and family members are just grateful for using either of those as opposed to the panic when they open the red box and say, Now what do I do? Thats when the 911 call usually happens.

Peter Salgo, MD: Anne, what do you vote for?

Anne Peters, MD: My patients caregivers or family members generally prefer the intranasal glucagon because theyre used to putting nasal spray in because their sinuses are bad or whatever. Thats something they relate to. I dont have that many family members who are used to giving epinephrine, so they tend to prefer the intranasal method. But its not about me; its about them.

Davida Kruger, MSN, APN-BC, BC-ADM: Yeah.

Anne Peters, MD: I offer it, and I have samples. I ask, Which 1 do you want? We also talk about insurance coverage, but if the world were neutral, its simply what a family member wants.

Davida Kruger, MSN, APN-BC, BC-ADM: Absolutely.

Anne Peters, MD: Ive shown people both, and they take whatever they want because its about using it. Ive had patients give it to themselvesthe intranasal stuffand they say it feels like a bullet to the brain. You dont want a conscious person using glucagon intranasally because its a very strong drug and a very strong push-up. But its working. Its really spraying that stuff in the back of your nose. Dont use it for conscious patients. Thats not a good thing.

Peter Salgo, MD: My thought is that after everybody has had a year of having tongs put up their noses for COVID-19 tests, we could all be desensitized to this. Jay, what do you think?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: Im agnostic. I feel like its whatever youre going to fill, whatever the family is comfortable givingthats what Im going to write. Because I treat both adults and kids, its all over the map in terms of the response. I need them to have confidence that they can give it, that they can afford it, and that they will fill it. Ill use any of them because when used properly, they can all work.

Peter Salgo, MD: I want to thank all of you at home for watching this HCPLive Peer Exchange. If you enjoyed the content, I want you to subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your in-box.

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Selecting or Switching Formulations of Glucagon - MD Magazine