Glucagon Dosing for Severe Hypoglycemia in Patients with Impaired Renal Function
For severe hypoglycemia in patients with impaired renal function, administer glucagon 1 mg (1000 mcg) intramuscularly, subcutaneously, or intranasally as a single dose, with the same dosing as patients with normal kidney function—renal impairment does not require dose adjustment for glucagon. 1
Standard Dosing Protocol
Adults and children ≥25 kg (or ≥6 years): 1 mg (1000 mcg) IM, SC, or 3 mg intranasal 1, 2
Children <25 kg (or <6 years): 0.5 mg (500 mcg) IM/SC 1, 2
The maximum single dose is 1 mg for intramuscular/subcutaneous routes, regardless of age or weight. 1 For intranasal formulations, the dose is 3 mg as a single administration. 3, 4
Frequency and Repeat Dosing
Single dose administration is standard. 1 If the patient does not respond adequately within 15 minutes to the initial 1 mg IM dose, switch to IV dextrose administration (20-40 mL of 50% glucose solution) rather than repeating glucagon. 1
Glucagon typically increases blood glucose within 5-15 minutes after administration. 1, 5 Blood glucose should be monitored every 15 minutes until levels exceed 70 mg/dL (3.9 mmol/L). 2
Critical Considerations for Renal Impairment
Renal function does not affect glucagon dosing or frequency. However, patients with impaired renal function on insulin therapy face increased hypoglycemia risk because: 6
- Lower insulin doses are required as eGFR decreases 6
- Risk of hypoglycemia increases with severity of kidney impairment 6
- Duration of insulin activity is prolonged in kidney disease 6
All patients with impaired renal function on insulin—even basal-only regimens—should be prescribed glucagon. 1
Route Selection and Formulation Preferences
Intranasal and ready-to-inject glucagon preparations are now preferred over traditional reconstitution kits because they are easier to administer by untrained caregivers and result in more rapid correction of hypoglycemia. 1 In simulation studies, caregivers administered intranasal glucagon within 1 minute versus 1.3-5 minutes with IM glucagon. 7
Multiple formulations are available: 1
- Traditional reconstitution kits (IM/SC)
- Pre-filled pens/syringes (IM/SC)
- Intranasal glucagon (3 mg single-use device)
Post-Administration Management
Once the patient responds and can swallow safely: 1, 2
- Give oral carbohydrates (15-20 g of glucose) immediately to restore liver glycogen and prevent secondary hypoglycemia 1, 2
- Follow with a meal or protein-containing snack 2
- Continue monitoring blood glucose to avoid overcorrection causing hyperglycemia 2
Common Pitfalls and Side Effects
Nausea and vomiting are common side effects, particularly with higher doses. 1, 5 The airway must be protected before glucagon administration in patients with altered mental status or seizures. 1, 2
Never attempt oral glucose in a seizing or unconscious patient due to aspiration risk. 2 Do not delay glucagon administration to obtain IV access in the prehospital or home setting. 2
Storage and Caregiver Training
Glucagon products should be replaced when they reach their expiration date and stored according to specific product instructions. 1, 5 Family members, roommates, school personnel, and coworkers should be trained on: 1
- Where the glucagon product is kept
- When to administer it
- How to administer it
- Explicit education to never administer insulin to individuals experiencing hypoglycemia