Emerging treatments

Newer glucagon formulations

Newer formulations of glucagon are available in some countries. These formulations are easier to use in hypoglycaemic emergencies compared with the traditional formulation, which requires several steps for reconstitution. An intranasal powder inhalation device is approved in the US and Europe for the treatment of severe hypoglycaemia in adult and paediatric patients aged 4 years and above with diabetes. A pre-filled subcutaneous autoinjector pen is approved in the US and Europe for the treatment of severe hypoglycaemia in adult and paediatric patients aged 2 years and above with diabetes. A pre-filled subcutaneous autoinjector containing the glucagon analogue dasiglucagon is approved in the US for the treatment of severe hypoglycaemia in adult and paediatric patients aged 6 years and above with diabetes. Dasiglucagon has a shelf-life of 36 months at refrigerated temperatures, and is stable for up to 12 months at room temperature. To date, there are no data on the use of these newer formulations in the inpatient setting, and these options are currently limited to outpatient use. However, the onset of action and efficacy in treating hypoglycaemia is non-inferior to the more traditional glucagon rescue kit.[48][49]

Continuous glucose monitoring and insulin pumps

Several continuous glucose monitoring (CGM) devices have been approved for hospital use in Europe (most sample glucose through the intravascular route, and one through the subcutaneous route) and in the US (intravascular route). Fingerstick capillary blood glucose has been the standard for monitoring in hospital inpatients but research has been looking at whether ambulatory CGMs may be appropriate in non-critically ill hospital patients. Initial studies on one device suggest that its use can assist in reducing hyperglycaemia and hypoglycaemia in the non-intensive care unit setting.[50] Use of the real-time CGM has been shown to lower the incidence of hypoglycaemia but potentially increases nursing workload.[32] With the coronavirus disease (COVID-19) pandemic, there was increasing utilisation of ambulatory CGM devices in the hospital setting. Inpatient data suggested that CGM devices have an accuracy in many scenarios that is on a par with point-of-care fingerstick blood glucose testing, with advantages including improved detection and prevention of hypo- and hyperglycaemic events.[51][52][53][54]​ The Endocrine Society recommends that selected inpatients at high risk for hypoglycaemia and adults with insulin-treated diabetes hospitalised for non-critical illness who are at high risk of hypoglycaemia should have real-time CGM with confirmatory bedside point-of-care blood glucose monitoring for adjustments in insulin dosing rather than point-of-care blood glucose testing alone. The use of CGM increases the detection of hypoglycaemic events.[4]​​​​[55]​​​​ If CGM is not available monitoring can be continued with point-of-care blood glucose testing as an alternative.[4]​​​ Examples of patients at high risk of hypoglycaemia include individuals older than 65 years, patients with type 1 diabetes who often have variable glycaemic control, patients requiring high-dose corticosteroids or parenteral/enteral nutrition and those with comorbid conditions that might further increase their risk.[55]​ The American Diabetes Association (ADA) recommend continued use of CGM in the hospital paired with confirmatory point-of-care testing in settings where appropriate resources and training are available.[1]​ Similarly, continued use of closed-loop insulin pumps is encouraged for inpatient use by both the ADA and Endocrine Society when an individual can independently manage the device and the clinical circumstances do not make their use unsafe.[1][55]

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