Skip to main content
SpringerLink
Log in

Cardiovascular and Adverse Effects of Glucagon for the Management of Suspected Beta Blocker Toxicity: a Case Series

  • Original Article
  • Published:
Journal of Medical Toxicology Aims and scope Submit manuscript

Abstract

Background

Although glucagon use in beta blocker toxicity has been recommended for many years, evidence for its safety and efficacy in humans is limited. This study aims to determine the magnitude of effect of glucagon on heart rate (HR) and systolic blood pressure (SBP) in patients with suspected beta blocker toxicity and describe potential adverse effects of the medication.

Methods

We conducted a retrospective, multi-center case series of patients greater than 12 years of age who received glucagon for suspected beta blocker toxicity. The primary outcome was the mean difference in HR from immediately pre- to 20-minutes post-glucagon administration. Secondary outcomes included the median difference in SBP, and occurrence of nausea, vomiting, and hyperglycemia.

Results

A total of 107 patients met inclusion criteria accounting for 144 glucagon orders. The mean difference in HR from pre- to post-glucagon administration was 4 bpm ± 10.6 (95% CI [2.25–5.76], p < 0.001). The median difference (IQR) in SBP was 4.5 (− 6 to 16) mmHg (p = 0.004). Similar increases were observed when patients receiving concomitant vasopressors were excluded. A total of nine glucagon administrations (6.3%) were associated with nausea and 14 (9.7%) with vomiting; however, 52 doses (36.1%) were administered concomitantly with antiemetic medications. Fifteen administrations (10.4%) were associated with hyperglycemia.

Conclusion

Glucagon administration was associated with a statistically significant increase in HR, but a small absolute difference of uncertain clinical significance. A similar observation was noted for SBP. Few patients experienced adverse events.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Brubacher JR, et al. Beta-adrenergic antagonists. In: Nelson LS, et al., editors. Goldfrank’s toxicologic emergencies. 11th ed. New York: McGraw-Hill; 2019. p. 856–69.

    Google Scholar 

  2. Howland M, et al. Antidotes in depth: glucagon. In: Nelson LS, et al., editors. Goldfrank’s toxicologic emergencies. 11th ed. New York: McGraw-Hill; 2019. p. 870–3.

    Google Scholar 

  3. Benoit B. Glucagon in beta blocker and calcium channel blocker overdoses: a systematic review. J Toxicol Clin Toxicol. 2003;41:595–602. https://doi.org/10.1081/clt-120023761.

    Article  Google Scholar 

  4. Kosinski EJ, Malindzak GS. Glucagon and isoproterenol in reversing propranolol toxicity. Arch Intern Med. 1973;132:840–3. https://doi.org/10.1001/archinte.1973.03650120048009.

    Article  CAS  Google Scholar 

  5. Ehgartner GR, Zelinka MA. Hemodynamic instability following intentional nadalol overdose. Arch Intern Med. 1988;148:801–2. https://doi.org/10.1001/archinte.1988.00380040041008.

    Article  CAS  Google Scholar 

  6. Lewis M, Kallenbach Germond C, Zaltzman N, Muller F, Steyn J, et al. Survival following massive overdose of adrenergic blocking agents (acebutolol and labetalol). Eur Heart J. 1983;4:328–32. https://doi.org/10.1093/oxfordjournals.eurheartj.a061469.

    Article  CAS  Google Scholar 

  7. O’Mahony D, O’Leary P, Molloy MG. Severe oxprenolol poisoning: the importance of glucagon infusion. Hum Exp Toxicol. 1990;9:101–3. https://doi.org/10.1177/09603271900090020.

    Article  Google Scholar 

  8. Smith RC, Wilkinson J, Jull RL. Glucagon for propranolol overdose. J Am Med Assoc. 1995;254:2412. https://doi.org/10.1001/jama.1985.03360170052022.

    Article  Google Scholar 

  9. Fernandes CMB, Daya MR. Sotalol-induced bradycardia reversed by glucagon. Can Fam Physician. 1995;41:659–65.

    CAS  Google Scholar 

  10. Salzberg M, Gallagher EJ. Propranolol overdose. Ann Emerg Med. 1989;9:26–7. https://doi.org/10.1016/S0196-0644(85)81081-7.

    Article  Google Scholar 

  11. Peterson C, Leeder S, Sterner S. Glucagon therapy for beta blocker overdose. Drug Intell Clin Pharm. 1984;18:394–8. https://doi.org/10.1177/106002808401800507.

    Article  CAS  Google Scholar 

  12. Love JN, Sachdeva DK, Bessmen ES, Curtis LA, Howell JM. A potential role for glucagon in the treatment of drug-induced symptomatic bradycardia. Chest. 1998;114:323–6. https://doi.org/10.1378/chest.114.1.323.

    Article  CAS  Google Scholar 

  13. Graudins A, Lee HM, Dino D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunctive therapies. Br J Clin Pharmacol. 2016;81:452–531. https://doi.org/10.1111/bcp.12763.

    Article  CAS  Google Scholar 

  14. Beta blocking agents. IN: POISONDEX System [database on the internet]. Greenwood Village (CO): IBM Corporation; 2022 [cited 2022 Sep 29] Available from www.micromedexcolutions.com. Subscription required to view.

  15. Glucagon [package insert]. Warrendale: Fresenius Kabi USA, LLC; 1960.

  16. Kline JA, Leonova E, Raymond RM. Beneficial myocardial metabolic effects of insulin during verapamil toxicity in the anesthetized caninie. Crit Care Med. 1995;23:1251–63.

    Article  CAS  Google Scholar 

  17. Petersen KM, Bøgevig S, Riis T, Andersen NW, Dalhoff KP, Holst JJ, et al. High-dose glucagon has hemodynamic effects regardless of cardiac beta-adenoreceptor blockade: a randomized clinical trial. J Am Heart Assoc. 2020;9:e016828. https://doi.org/10.1161/CIR.0000000000000628.

    Article  CAS  Google Scholar 

Download references

Funding

No funding was provided.

Author information

Authors and Affiliations

  1. Department of Pharmacy, Greater Baltimore Medical Center, 6701 N. Charles St., MD, 21204, Towson, USA

    Alicia M. Senart

  2. Department of Pharmacy, Inova Fairfax Medical Campus, 3300 Gallows Rd., VA, 22042, Falls Church, USA

    Lorrie A. LeClair

Authors
  1. Alicia M. Senart
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lorrie A. LeClair
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LAL conceived the study. AMS and LAL designed the study. AMS performed data collection. AMS and LAL analyzed the data. AMS drafted the manuscript; and AMS and LAL contributed substantially to its revision. AMS and LAL take responsibility for the paper as a whole.

Corresponding author

Correspondence to Lorrie A. LeClair.

Ethics declarations

Conflict of Interest

None.

Additional information

Supervising Editor: Michael Levine, MD

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Prior Presentations: Data in this manuscript were previously presented at North American Congress of Clinical Toxicology (NACCT) meeting, Virtual, 2021.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Senart, A.M., LeClair, L.A. Cardiovascular and Adverse Effects of Glucagon for the Management of Suspected Beta Blocker Toxicity: a Case Series. J. Med. Toxicol. 19, 9–15 (2023). https://doi.org/10.1007/s13181-022-00919-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13181-022-00919-x

Keywords

Search

Navigation