IV Glucagon for Dysphagia: Not Recommended
IV glucagon should not be used for the treatment of dysphagia, as it lacks efficacy and offers no advantage over placebo, while causing significant adverse effects including nausea and vomiting. 1, 2
Evidence Against Glucagon Use
Efficacy Data
A multicenter retrospective study of 127 patients receiving glucagon for esophageal food impaction demonstrated only 14.2% resolution, which was not significantly different from the control group that received no glucagon (10.3%, p = 0.586) 1
A separate study of 92 episodes of food impaction showed that only 33% resolved after glucagon administration, a rate comparable to placebo in previously published trials 2
The lack of advantage over placebo fundamentally questions the practice of glucagon administration for esophageal food impaction 2
Mechanism and Physiologic Effects
While glucagon does reduce lower esophageal sphincter (LES) resting pressure—with 0.25 mg reducing mean LES pressure from 18.7 mmHg to 10.2 mmHg (p = 0.0001)—this physiologic effect does not translate into clinical benefit 3
Glucagon significantly impairs esophageal peristalsis by reducing distal esophageal contraction amplitude and decreasing the efficiency of esophageal stripping (p = 0.05 at 2 minutes post-injection) 4
The drug reduces mean LES relaxation from 93.1% to 63.6% after 0.25 mg (p = 0.0031), which may paradoxically worsen rather than improve food passage 3
Adverse Effects
Nausea is a common side effect, occurring in 12.6% of patients overall, with 40% of patients experiencing nausea after the 1 mg dose 3, 1
Concomitant administration of benzodiazepines or nitroglycerin with glucagon was associated with significantly lower success rates (33.3% vs 59.6%, p = 0.04) 1
The combination of low efficacy and significant adverse effects makes glucagon an unfavorable therapeutic option 1
Appropriate Management of Dysphagia
Functional Dysphagia
For functional dysphagia, positive diagnostic signs include inability to swallow in the absence of drooling or excessive oral secretions, or inability to control anything in the mouth but ability to spit saliva into a cup 5
Speech and language therapy with swallowing rehabilitation is the appropriate treatment approach for functional dysphagia, not pharmacologic intervention 5
Esophageal Food Impaction
Urgent endoscopy is indicated for patients unable to tolerate sufficient liquid diet, with food impaction, or with foreign body impaction 6
Esophagogastroduodenoscopy (EGD) with esophageal biopsies is the first-line diagnostic and therapeutic approach, with a diagnostic yield exceeding 75% 6
In the multicenter glucagon study, 84% of patients in the unsuccessful glucagon group ultimately required endoscopy, demonstrating that glucagon primarily delays definitive management 1
Neurological Dysphagia
For severe neurological dysphagia, enteral nutrition via nasogastric tube or percutaneous endoscopic gastrostomy (PEG) should be initiated as soon as possible to ensure adequate energy and nutrient supply 5
PEG is preferred over nasogastric tube for long-term support, as it is associated with fewer treatment failures and better nutritional status 5
Enteral nutrition should accompany intensive swallowing therapy until safe and sufficient oral intake is possible 5
Clinical Pitfalls to Avoid
Do not delay definitive management: Administering glucagon delays endoscopy in the majority of patients without providing benefit 1, 2
Do not rely on symptom location alone: Obstructive symptoms perceived in the throat or neck may actually originate from distal esophageal lesions, requiring evaluation of the entire esophagus and gastric cardia 6
Do not skip esophageal biopsies during endoscopy: Eosinophilic esophagitis can present with normal-appearing mucosa, and biopsies are essential for diagnosis 6
Recognize silent aspiration: Up to 55% of patients who aspirate demonstrate silent aspiration without a protective cough reflex, making clinical diagnosis difficult 5