Restrictions on EMT glucagon administration should be lifted

ORLANDO – In 42 states, emergency medical technicians aren’t allowed to administer glucagon to patients with severe hypoglycemia, and that’s a problem, according to investigators from the Joslin Diabetes Center, Boston.

Paramedics can administer the drug, but they’re only about a quarter of medical first-responders, so in many parts of the country, ambulance crews show up with only EMTs [emergency medical technicians] on board, and patients have to wait for the ED to get glucagon.

The delay increases the risk of coma, brain damage, and death. Just like in stroke, time is key with severe hypoglycemia. “The minutes really add up,” said lead investigator Nicole Wagner, a one-time researcher at Joslin and now a medical student at Thomas Jefferson Medical College, Philadelphia.

“Increasing the availability of glucagon in the prehospital setting will likely result in reduced cost burden and adverse consequences of severe hypoglycemia. All emergency persons should have access to glucagon along with the training to administer it,” she and her team concluded at the 2018 American Diabetes Association scientific sessions meeting.

The situation is puzzling because glucagon has a good safety profile – the main concern is nausea – and families of diabetics, at least at Joslin, are taught all the time how to mix and inject it.

One of the investigators, a former EMT, ran into the problem when he was working in New York, so the team wanted to find out how widespread it is. They called emergency medical services offices in all 50 states and asked about their glucagon protocols. “We were surprised [by what we found]. We didn’t expect it,” Ms. Wagner said.

In some states, EMTs aren’t even allowed to check blood glucose.

In the eight states that allow EMTs to administer glucagon – Alaska, Montana, Minnesota, Wisconsin, Illinois, Kansas, Virginia, and Rhode Island – it seemed that someone at some point got fired up and lobbied for change. In the other states seemed to have fallen through the cracks. “When we pressed the offices a little bit, we” were told about bureaucratic red tape, “and that maybe it’s something that would be considered down the line,” Ms. Wagner said.

The Joslin team wants to get proactive. Joslin is one of the nation’s leading diabetes institutions, and it has worked on advocacy before. EMT glucagon might be its next campaign. “It’s something we feel should be addressed. We could work with the EMT community to push this through,” she said.

Meanwhile, the glucagon autoinjectors and nasal sprays companies are working on might alleviate the problem. Time will tell.

The team also looked at the 89,263 cases in the National Emergency Management Information System from 2013-2015 in which glucagon was administered; it’s likely the number would have been far higher if EMTs were allowed to give the drug.

Ambulances showed up an average of 15.34 minutes after the first call. Meanwhile, there were 3,944 adverse events with glucagon, mostly nausea.

Less than half of the cases were dispatched correctly as “diabetic problems,” so it’s likely that EMTs who couldn’t give glucagon handled the call.

There was no industry funding for the work. Ms. Wagner had no disclosures.

[email protected]

SOURCE: Wagner NE et al. 2018 American Diabetes Association scientific sessions abstract 387-P

ORLANDO – In 42 states, emergency medical technicians aren’t allowed to administer glucagon to patients with severe hypoglycemia, and that’s a problem, according to investigators from the Joslin Diabetes Center, Boston.

Paramedics can administer the drug, but they’re only about a quarter of medical first-responders, so in many parts of the country, ambulance crews show up with only EMTs [emergency medical technicians] on board, and patients have to wait for the ED to get glucagon.

The delay increases the risk of coma, brain damage, and death. Just like in stroke, time is key with severe hypoglycemia. “The minutes really add up,” said lead investigator Nicole Wagner, a one-time researcher at Joslin and now a medical student at Thomas Jefferson Medical College, Philadelphia.

“Increasing the availability of glucagon in the prehospital setting will likely result in reduced cost burden and adverse consequences of severe hypoglycemia. All emergency persons should have access to glucagon along with the training to administer it,” she and her team concluded at the 2018 American Diabetes Association scientific sessions meeting.

The situation is puzzling because glucagon has a good safety profile – the main concern is nausea – and families of diabetics, at least at Joslin, are taught all the time how to mix and inject it.

One of the investigators, a former EMT, ran into the problem when he was working in New York, so the team wanted to find out how widespread it is. They called emergency medical services offices in all 50 states and asked about their glucagon protocols. “We were surprised [by what we found]. We didn’t expect it,” Ms. Wagner said.

In some states, EMTs aren’t even allowed to check blood glucose.

In the eight states that allow EMTs to administer glucagon – Alaska, Montana, Minnesota, Wisconsin, Illinois, Kansas, Virginia, and Rhode Island – it seemed that someone at some point got fired up and lobbied for change. In the other states seemed to have fallen through the cracks. “When we pressed the offices a little bit, we” were told about bureaucratic red tape, “and that maybe it’s something that would be considered down the line,” Ms. Wagner said.

The Joslin team wants to get proactive. Joslin is one of the nation’s leading diabetes institutions, and it has worked on advocacy before. EMT glucagon might be its next campaign. “It’s something we feel should be addressed. We could work with the EMT community to push this through,” she said.

Meanwhile, the glucagon autoinjectors and nasal sprays companies are working on might alleviate the problem. Time will tell.

The team also looked at the 89,263 cases in the National Emergency Management Information System from 2013-2015 in which glucagon was administered; it’s likely the number would have been far higher if EMTs were allowed to give the drug.

Ambulances showed up an average of 15.34 minutes after the first call. Meanwhile, there were 3,944 adverse events with glucagon, mostly nausea.

Less than half of the cases were dispatched correctly as “diabetic problems,” so it’s likely that EMTs who couldn’t give glucagon handled the call.

There was no industry funding for the work. Ms. Wagner had no disclosures.

[email protected]

SOURCE: Wagner NE et al. 2018 American Diabetes Association scientific sessions abstract 387-P

ORLANDO – In 42 states, emergency medical technicians aren’t allowed to administer glucagon to patients with severe hypoglycemia, and that’s a problem, according to investigators from the Joslin Diabetes Center, Boston.

Paramedics can administer the drug, but they’re only about a quarter of medical first-responders, so in many parts of the country, ambulance crews show up with only EMTs [emergency medical technicians] on board, and patients have to wait for the ED to get glucagon.

The delay increases the risk of coma, brain damage, and death. Just like in stroke, time is key with severe hypoglycemia. “The minutes really add up,” said lead investigator Nicole Wagner, a one-time researcher at Joslin and now a medical student at Thomas Jefferson Medical College, Philadelphia.

“Increasing the availability of glucagon in the prehospital setting will likely result in reduced cost burden and adverse consequences of severe hypoglycemia. All emergency persons should have access to glucagon along with the training to administer it,” she and her team concluded at the 2018 American Diabetes Association scientific sessions meeting.

The situation is puzzling because glucagon has a good safety profile – the main concern is nausea – and families of diabetics, at least at Joslin, are taught all the time how to mix and inject it.

One of the investigators, a former EMT, ran into the problem when he was working in New York, so the team wanted to find out how widespread it is. They called emergency medical services offices in all 50 states and asked about their glucagon protocols. “We were surprised [by what we found]. We didn’t expect it,” Ms. Wagner said.

In some states, EMTs aren’t even allowed to check blood glucose.

In the eight states that allow EMTs to administer glucagon – Alaska, Montana, Minnesota, Wisconsin, Illinois, Kansas, Virginia, and Rhode Island – it seemed that someone at some point got fired up and lobbied for change. In the other states seemed to have fallen through the cracks. “When we pressed the offices a little bit, we” were told about bureaucratic red tape, “and that maybe it’s something that would be considered down the line,” Ms. Wagner said.

The Joslin team wants to get proactive. Joslin is one of the nation’s leading diabetes institutions, and it has worked on advocacy before. EMT glucagon might be its next campaign. “It’s something we feel should be addressed. We could work with the EMT community to push this through,” she said.

Meanwhile, the glucagon autoinjectors and nasal sprays companies are working on might alleviate the problem. Time will tell.

The team also looked at the 89,263 cases in the National Emergency Management Information System from 2013-2015 in which glucagon was administered; it’s likely the number would have been far higher if EMTs were allowed to give the drug.

Ambulances showed up an average of 15.34 minutes after the first call. Meanwhile, there were 3,944 adverse events with glucagon, mostly nausea.

Less than half of the cases were dispatched correctly as “diabetic problems,” so it’s likely that EMTs who couldn’t give glucagon handled the call.

There was no industry funding for the work. Ms. Wagner had no disclosures.

[email protected]

SOURCE: Wagner NE et al. 2018 American Diabetes Association scientific sessions abstract 387-P