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Glucagon for Injection, for intravenous or intramuscular use, is a gastrointestinal motility inhibitor that is produced by solid phase peptide synthesis. Glucagon is a single-chain polypeptide containing 29 amino acid residues. The chemical structure of the glucagon polypeptide is identical to human glucagon and to glucagon extracted from beef and pork pancreas. The structure of glucagon is:
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Glucagon for Injection is a sterile, lyophilized white powder in a 3 mL vial. The reconstituted solution contains 1 mg of glucagon as hydrochloride per mL and lactose monohydrate (107 mg). Glucagon for Injection is supplied at pH 2.5 to 3.5 and is soluble in water.
Glucagon for Injection is indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes.
Glucagon for Injection is indicated as a diagnostic aid for use during radiologic examinations to temporarily inhibit movement of the gastrointestinal tract in adult patients.
Glucagon for Injection is for subcutaneous, intramuscular, or intravenous injection. Administer intravenously ONLY under medical supervision.
Instruct patients and their caregivers on the signs and symptoms of severe hypoglycemia. Because severe hypoglycemia requires the help of others to recover, instruct the patient to inform those around them about Glucagon for Injection and its Instructions for Use. Administer Glucagon for Injection as soon as possible when severe hypoglycemia is recognized.
Instruct the patient or caregiver to read the Instructions for Use at the time they receive a prescription for Glucagon for Injection. Emphasize the following instructions to the patient or caregiver:
Glucagon for Injection is a white lyophilized powder supplied as follows:
Glucagon for Injection is supplied as a lyophilized white powder available as follows:
| Presentation | NDC | Strength | Description |
| Treatment of Severe Hypoglycemia | |||
| Glucagon Emergency Kit for Low Blood Sugar | 63323-582-82 | 1 mg per vial | 1 mL single-dose vial of Glucagon for Injection with 1 mL single-dose syringe of Sterile Water for Injection, USP for reconstitution |
| Use as a Diagnostic Aid | |||
| 10 Single-dose vials | 63323-596-13 | 1 mg per vial | 1 mL single-dose vial of Glucagon for Injection |
| Diagnostic Kit | 63323-593-03 | 1 mg per vial | 1 mL single-dose vial of Glucagon for Injection with 1 mL single-dose vial of Sterile Water for Injection, USP for reconstitution |
Before Reconstitution
The package containing Glucagon for Injection vials may be stored up to 24 months at 20° to 25° C (68° to 77° F) prior to reconstitution. Do not freeze. Keep in the original package to protect from light.
After Reconstitution
Use reconstituted glucagon solution immediately. Discard any unused portion [see DOSAGE AND ADMINISTRATION].
Manufactured by: Fresenius Kabi Lake Zurich, IL 60047. Revised: Sep 2019.
The following important adverse reactions are described below and elsewhere in the labeling:
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in clinical trials of another drug and may not reflect the rates observed in practice.
In a randomized single-blind clinical study of Glucagon for Injection, 29 healthy subjects received a single dose of 1 mg Glucagon for Injection intramuscularly. Table 1 shows the most common adverse reactions that were not present at baseline and occurred in at least 5% of patients.
Table 1: Adverse Reactions Occurring in ≥ 5% of Healthy Subjects Who Received Glucagon for Injection Intramuscularly
| Glucagon for Injection (N=29) % of Patients |
|
| Nausea | 17 |
| Vomiting | 7 |
In a randomized, single-blind clinical study of Glucagon for Injection, 31 healthy subjects received a single dose of 1 mg Glucagon for Injection subcutaneously. Table 2 shows the most common adverse reactions that were not present at baseline and occurred in at least 5% of patients. (2.1)].
Table 2: Adverse Reactions Occurring ≥5% in Healthy Subjects Who Received Glucagon for Injection Subcutaneously
| Glucagon for Injection (N=31) % of Patients |
|
| Injection site swelling | 58 |
| Injection site erythema | 55 |
| Vomiting | 36 |
| Nausea | 32 |
| Decreased blood pressure | 23 |
| Asthenia | 23 |
| Headache | 13 |
| Dizziness | 10 |
| Pallor | 10 |
| Diarrhea | 7 |
| Somnolence | 7 |
Hypertension and tachycardia have occurred with glucagon treatment.
Additional adverse reactions have been identified during post-approval use of glucagon. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Table 3: Clinically Significant Drug Interactions with Glucagon for Injection
| Beta-Blockers | |
| Clinical Impact: | Patients taking beta-blockers may have a transient increase in pulse and blood pressure when given Glucagon for Injection. |
| Intervention: | The increase in blood pressure and heart rate may require therapy in patients with coronary artery disease. |
| Indomethacin | |
| Clinical Impact: | In patients taking indomethacin, Glucagon for Injection may lose its ability to raise blood glucose or may even produce hypoglycemia. |
| Intervention: | Monitor blood glucose levels during glucagon treatment of patients taking indomethacin. |
| Anticholinergic Drugs | |
| Clinical Impact: | The concomitant use of anticholinergic drugs and Glucagon for Injection increases the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. |
| Intervention: | Concomitant use of anticholinergic drugs with Glucagon for Injection for use as a diagnostic aid is not recommended. |
| Warfarin | |
| Clinical Impact: | Glucagon for Injection may increase the anticoagulant effect of warfarin. |
| Intervention: | Monitor patients for unusual bruising or bleeding, as adjustments in warfarin dosage may be required. |
| Insulin | |
| Clinical Impact: | Insulin acts antagonistically to glucagon. |
| Intervention: | Monitor blood glucose when Glucagon for Injection is used as a diagnostic aid in patients receiving insulin. |
Included as part of the "PRECAUTIONS" Section
Glucagon for Injection is contraindicated in patients with pheochromocytoma because glucagon may stimulate the release of catecholamines from the tumor [see CONTRAINDICATIONS]. If the patient develops a substantial increase in blood pressure and a previously undiagnosed pheochromocytoma is suspected, 5 to 10 mg of phentolamine mesylate, administered intravenously, has been shown to be effective in lowering blood pressure.
In patients with insulinoma, administration of glucagon may produce an initial increase in blood glucose; however, Glucagon for Injection administration may directly or indirectly (through an initial rise in blood glucose) stimulate exaggerated insulin release from an insulinoma and cause hypoglycemia. Glucagon for Injection is contraindicated in patients with insulinoma [see CONTRAINDICATIONS]. If a patient develops symptoms of hypoglycemia after a dose of Glucagon for Injection, give glucose orally or intravenously.
Allergic reactions have been reported with glucagon, these include generalized rash, and in some cases anaphylactic shock with breathing difficulties and hypotension. Glucagon for Injection is contraindicated in patients with a prior hypersensitivity reaction [see CONTRAINDICATIONS].
Glucagon for Injection is effective in treating hypoglycemia only if sufficient hepatic glycogen is present. Patients in states of starvation, with adrenal insufficiency or chronic hypoglycemia may not have adequate levels of hepatic glycogen for Glucagon for Injection administration to be effective. Patients with these conditions should be treated with glucose.
Necrolytic migratory erythema (NME), a skin rash commonly associated with glucagonomas (glucagonproducing tumors) and characterized by scaly, pruritic erythematous plaques, bullae, and erosions, has been reported postmarketing following continuous glucagon infusion. NME lesions may affect the face, groin, perineum and legs or be more widespread. In the reported cases NME resolved with discontinuation of the glucagon, and treatment with corticosteroids was not effective. Should NME occur, consider whether the benefits of continuous glucagon infusion outweigh the risks.
Treatment with Glucagon for Injection in patients with diabetes mellitus may cause hyperglycemia. Monitor diabetic patients for changes in blood glucose levels during treatment and treat if indicated.
Glucagon for Injection may increase myocardial oxygen demand, blood pressure, and pulse rate which may be life-threatening in patients with cardiac disease. Cardiac monitoring is recommended in patients with cardiac disease during use of Glucagon for Injection as a diagnostic aid, and an increase in blood pressure and pulse rate may require therapy.
Glucagon administered to patients with glucagonoma may cause secondary hypoglycemia. Glucagon for Injection is contraindicated in patients with glucagonoma when used as a diagnostic aid [see CONTRAINDICATIONS]. Test patients suspected of having glucagonoma for blood levels of glucagon prior to treatment, and monitor for changes in blood glucose levels during treatment. If a patient develops symptoms of hypoglycemia after a dose of Glucagon for Injection, give glucose orally or intravenously.
Advise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION and Instructions for Use).
Inform patient and family members or caregivers on how to recognize the signs and symptoms of severe hypoglycemia and the risks of prolonged hypoglycemia.
Review the Patient Information and Instructions for Use with the patient and family members or caregivers.
Inform patients that allergic reactions can occur with Glucagon for Injection. Advise patients to seek immediate medical attention if they experience any symptoms of serious hypersensitivity reactions [see WARNINGS AND PRECAUTIONS].
Long term studies in animals to evaluate carcinogenic potential have not been performed.
Synthetic glucagon was negative in the bacterial reverse mutation assay (Ames test). The clastogenic potential of synthetic glucagon in the Chinese Hamster Ovary (CHO) assay was positive in the absence of metabolic activation. Doses of 100 and 200 mg/kg of glucagon of both pancreatic and recombinant origins gave slightly higher incidences of micronucleus formation in male mice but there was no effect in females. The weight of evidence indicates that synthetic and recombinant glucagon are not different and do not pose a genotoxic risk to humans.
Glucagon was not tested in animal fertility studies. Studies in rats have shown that pancreatic glucagon does not cause impaired fertility.
Available data from case reports and a small number of observational studies with glucagon use in pregnant women over decades of use have not identified a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. Multiple small studies have demonstrated a lack of transfer of pancreatic glucagon across the human placental barrier during early gestation. In rat and rabbit reproduction studies, no embryofetal toxicity was observed with glucagon administered by injection during the period of organogenesis at doses representing up to 100 and 200 times the human dose, respectively, based on body surface area (mg/m2) (see Data).
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2%-4% and 15%-20%, respectively.
Animal Data
In rats and rabbits given glucagon by injection at doses of 0.4, 2.0, and 10 mg/kg (up to 100 and 200 times the human dose based on mg/m2 for rats and rabbits, respectively) there was no evidence of increased malformations or embryofetal lethality.
There is no information available on the presence of glucagon in human or animal milk, the effects of glucagon on the breastfed child or the effects of glucagon on milk production. However, glucagon is a peptide and would be expected to be broken down to its constituent amino acids in the infant's digestive tract and is therefore, unlikely to cause harm to an exposed infant.
The safety and effectiveness of Glucagon for Injection for the treatment of severe hypoglycemia in pediatric patients with diabetes have been established.
Safety and effectiveness for use as a diagnostic aid during radiologic examinations to temporarily inhibit movement of the gastrointestinal tract in pediatric patients have not been established.
If overdosage occurs, the patient may experience nausea, vomiting, inhibition of GI tract motility, increase in blood pressure and pulse rate. In case of suspected overdosing, the serum potassium may decrease and should be monitored and corrected if needed. If the patient develops a dramatic increase in blood pressure, phentolamine mesylate has been shown to be effective in lowering blood pressure for the short time that control would be needed.
Glucagon for Injection is contraindicated in patients with:
Glucagon increases blood glucose concentration by activating hepatic glucagon receptors, thereby stimulating glycogen breakdown and release of glucose from the liver. Hepatic stores of glycogen are necessary for glucagon to produce an antihypoglycemic effect. Extrahepatic effects of glucagon include relaxation of the smooth muscle of the stomach, duodenum, small bowel, and colon.
Blood glucose concentration rises within 10 minutes of injection and maximal concentrations are attained at approximately 30 minutes after injection (see Figure 1). The duration of hyperglycemic action after intravenous or intramuscular injection is 60 to 90 minutes.
Figure 1: Recovery from Insulin Induced Hypoglycemia (mean blood glucose) After Intramuscular Injection of 1 mg of Another Glucagon for Injection Product in Type I Diabetic Men
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Table 4: Pharmacodynamic Properties of Another Glucagon for Injection Product For Intravenous Route
| Route of Administration | Dosea | Time of Maximal Glucose Concentration | Time of Onset of Action for GI Smooth Muscle Relaxation | Duration of Smooth Muscle Relaxation |
| Intravenous | 0.25 to 0.5 mg | 5 to 20 minutes | 45 seconds | 9 to 17 minutes |
| a Dose is determined based on the length of the procedure. | ||||
Table 5 Pharmacodynamic Properties of Another Glucagon for Injection Product For Intramuscular Route
| Route of Administration | Dosea | Time of Maximal Glucose Concentration | Time of Onset of Action for GI Smooth Muscle Relaxation | Duration of Smooth Muscle Relaxation |
| Intramuscular | 1 mg | 30 minutes | 8 to 10 minutes | 12 to 27 minutes |
| 2 mg | 30 minutes | 4 to 7 minutes | 21 to 32 minutes | |
| a Dose is determined based on the length of the procedure. | ||||
20In a study in healthy subjects, a subcutaneous dose of 1 mg Glucagon for Injection resulted on average a peak blood glucose concentration of 79.3 mg/dL with a median time of 50 minutes after injection.
Following subcutaneous administration of Glucagon for Injection, the median time to reach the maximum baseline uncorrected plasma glucagon concentrations of 3533 pg/mL was approximately 10 to 13 minutes after dosing Following intramuscular administration of 1 mg dose, the maximum baseline uncorrected plasma glucagon concentrations of 3391 pg/mL were attained approximately 10 minutes after dosing.
The mean apparent half-life of glucagon was about 42 minutes after subcutaneous administration. The mean apparent half-life of glucagon was 26 minutes after intramuscular administration.
Metabolism
Glucagon is degraded in the liver, kidney, and plasma.
Glucagon
(GLOO-ka-gon)
for injection, for subcutaneous, intramuscular or
intravenous use
What is Glucagon?
Glucagon is a prescription medicine used:
Who should not use Glucagon?
What should I tell my doctor before using Glucagon?
Before using Glucagon, tell your doctor about all of your medical conditions, including if you:
Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. Glucagon may affect the way other medicines work, and other medicines may affect how Glucagon works. Know the medicines you take. Keep a list of them to show your doctor and pharmacist when you get a new medicine.
How should I use Glucagon?
What are the possible side effects of Glucagon?
Glucagon may cause serious side effects, including:
The most common side effects of Glucagon include:
Tell your doctor if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of Glucagon. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
How should I store Glucagon?
Before you mix the Glucagon powder and liquid:
After you mix the Glucagon powder and liquid:
Keep Glucagon and all medicines out of the reach of children.
General information about the safe and effective use of Glucagon.
Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use Glucagon for a condition for which it was not prescribed. Do not give Glucagon to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about Glucagon that is written for health professionals.
What are the ingredients in the Glucagon?
Active Ingredient:Glucagon
Inactive ingredients: lactose monohydrate and sterile water for reconstitution
This Patient Information has been approved by the U.S. Food and Drug Administration.
INSTRUCTIOS FOR USE
Glucagon
(GLOO-ka-gon)
for injection, for subcutaneous, intramuscular or
intravenous use
Read this Instructions for Use before you start using Glucagon and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or treatment.
Talk to your doctor or pharmacist if you have any questions about how to use Glucagon.
Important:
How should I store Glucagon?
Before you mix the Glucagon powder and liquid:
After you mix the Glucagon powder and liquid:
Supplies you will need for your Glucagon injection (See Figure A):
Figure A
 |
Preparing the Glucagon dose:
Step 1. Using your thumb, flip the orange plastic cap off the Glucagon vial (See Figure B).
Figure B
 |
Step 2. Pick up the prefilled syringe containing sterile water. Hold the syringe with 1 hand and with your other hand pull the needle cover off the syringe (See Figure C).
Figure C
 |
backstop from the syringe.
Step 3. Pick up the Glucagon vial. Hold the vial of dry powder with 1 hand and with your other hand push the needle of the prefilled syringe through the center of the rubber stopper (See Figure D).
Figure D
 |
Step 4. Hold the vial and syringe together, with the needle still inserted into the vial. Carefully turn the vial and syringe together right side up. Slowly push the plunger down until the syringe is empty (See Figure E).
Figure E
 |
Step 5. Hold the entire unit (the vial and syringe) in 1 hand and gently shake the vial until the powder is completely dissolved (See Figure F).
Figure F
 |
Step 6. Firmly hold the vial and syringe together, with the needle still inserted into the vial. Carefully turn the vial and syringe together upside down. Gently pull down on the plunger and slowly withdraw all of the liquid into the syringe (See Figure G).
Figure G
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Step 7. Keep the needle inside the vial. Check the syringe for air bubbles. If you see bubbles, tap the syringe until the bubbles rise to the top of the syringe (See Figure H). Gently push on the plunger to move only the air bubbles back into the vial.
Figure H
 |
Step 8. Hold the vial and syringe as shown (See Figure I)
Figure I
 |
Giving the Glucagon for Injection:
Step 9. Choose the injection site (See Figure J).
Figure J
 |
Common injection sites for Glucagon are upper arms, thighs, or buttocks. Patient does not need to be laying down to administer the medication as long as the common injection sites can be easily accessed.
Step 10. With 1 hand gently pinch the skin at the injection site. With your other hand insert the needle into the skin and push the syringe plunger down until the syringe is empty (See Figure K).
Figure K
 |
After Giving the Glucagon injection:
Step 11. Pull the needle out of the skin and press on the injection site (See Figure L). Use a gauze pad or cotton ball (not included in the kit) if needed to press the injection site to make sure there is no direct contact with the skin.
Figure L
 |
Throw away your used syringe with the needle attached and any Glucagon you did not use. See “How should I dispose of (throw away) used Glucagon prefilled syringes” at the end of these instructions.
Step 12. Turn the person on their side. When an unconscious person awakens, they may vomit. Turning the person on their side will lessen the chance of choking.
Step 13. Call for emergency medical help right away. If the person does not respond after 15 minutes, another dose may be given, if available.
Step 14. Feed the person as soon as they are awake and able to swallow.
Give the person a fast acting source of sugar (such as a regular soft drink or fruit juice) and a long acting source of sugar (such as crackers and cheese or a meat sandwich).
Step 15. Even if the Glucagon for Injection treatment wakes the person, tell their doctor right away. The doctor should be told whenever a severe drop in blood sugar (hypoglycemia reaction) happens. The person’s dose of diabetes medicine may need to be changed.
Hypoglycemia may happen again after receiving Glucagon for Injection treatment.
Early symptoms of hypoglycemia may include:
If not treated early, hypoglycemia may worsen and the person may have severe hypoglycemia. Signs of severe hypoglycemia include:
How should I dispose of (throw away) Glucagon pre-filled syringes?
Keep Glucagon and all medicines out of the reach of children.
This Instructions for Use has been approved by the U.S. Food and Drug Administration.
