# EpiPen and diabetes



## EMTtoBE (Jun 29, 2010)

I was talking to an older man (late 50's early 60's) and he has diabetes (dont now if its type 1 or 2) but he said his doctor perscribed him an EpiPen for it..I have never heard this and what would it do for him if true? 

thank you


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## LucidResq (Jun 29, 2010)

Are you sure he didn't mean an insulin pen?


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## EMTtoBE (Jun 29, 2010)

I may have heard him wrong but i sure did sound like EpiPen


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## Sandog (Jun 29, 2010)

The epi pen is for an allergic reaction Epi as in Epinephrine. 

Maybe the guy has an allergy as well as diabetes.


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## usafmedic45 (Jun 29, 2010)

I had a patient one time tell me his doctor put him on Latex for his congestive heart failure.  I responded with "I bet that news thrills your wife" and asked if he was sure that it was not Lasix.  Patients are notoriously unreliable with this sort of thing.


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## EMTtoBE (Jun 29, 2010)

It could have been insulin pen...but yea patients arent always aware of what they are taking lol..but after reading i found that it can increase blood sugar levels so dunno lol should have used Google before lol thanks though


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## redcrossemt (Jun 29, 2010)

Likely a Glucagon injector. I've seen these a fair number of times.


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## LucidResq (Jun 29, 2010)

redcrossemt said:


> Likely a Glucagon injector. I've seen these a fair number of times.



I completely forgot about those. That's a very likely possibility, seeing as glucagon kits are for emergency use like EpiPens. The ones I've seen are not autoinjectors, though.


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## usafmedic45 (Jun 29, 2010)

> It could have been insulin pen...but yea patients arent always aware of what they are taking lol..but after reading i found that it can increase blood sugar levels so dunno lol should have used Google before lol thanks though



Yes, increases in glucose levels are one of the effects of epinephrine (as part of the "fight or flight" response).  However, it is never used clinically for this purpose mostly because of the risk of cardiac events.


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## MMiz (Jun 29, 2010)

I've seen both Insulin pens for hyperglycemia, and Glucagon pens for the treatment of hypoglycemia.  The insulin pens looks very similar to the Epi pens.  I've never used any of them, but I train on all three once a year.


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## ajax (Jun 29, 2010)

Epipens have one (or sometimes two) possible doses. Insulin pens you dial up the dose - most can do anything from 1 unit to 60 or so; some even have half-units. They come in many colors. Glucagon kits are usually bright red. When you open the kit, you see a huge syringe with liquid and a vial with liquid. To use the glucagon, you inject the syringe into the vial, mix, draw it all back into the syringe, and stab your pt. Nothing at all auto about glucagon. 

I would guess he meant an insulin pen, and either you heard him wrong or he said it wrong. But still a good idea to double check allergies.


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## usafmedic45 (Jun 30, 2010)

> Epipens have one (or sometimes two) possible doses.



Wrong, there are two different doses (0.3 or 0.15 mg) and they come in separate packaging.  It's not a "dial-a-dose" feature like you see on the insulin pens.



> you see a huge syringe with liquid and a vial with liquid.



It's actually a pretty small syringe since it is intended to be able to be carried in a purse or pocket  (I seem to recall it's a short 2 or 3ml syringe) and  it contains freeze-dried (or more technically lyophilized) glucagon.  

Here's the prescribing information and proper instructions: http://pi.lilly.com/us/rglucagon-ppi.pdf


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## Aidey (Jun 30, 2010)

usafmedic45 said:


> Wrong, there are two different doses (0.3 or 0.15 mg) and they come in separate packaging.  It's not a "dial-a-dose" feature like you see on the insulin pens.



I think they may have meant the double dose Epi pens - One pen with two doses inside of it.


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## redcrossemt (Jun 30, 2010)

Aidey said:


> I think they may have meant the double dose Epi pens - One pen with two doses inside of it.



The Twin-Ject is the brand that you're thinking of with two doses. I know the second dose is not an auto-injector, I forget if the first is or not.

The Epi-Pen is a different brand and only provides one dose. It is a true auto-injector.


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## ajax (Jul 1, 2010)

redcrossemt said:


> The Twin-Ject is the brand that you're thinking of with two doses. I know the second dose is not an auto-injector, I forget if the first is or not.
> 
> The Epi-Pen is a different brand and only provides one dose. It is a true auto-injector.



True story, I should have been clearer. I have always referred to any epi that isn't literally drawn up by me or pushed IV as an epipen, since being a very young (8 year old, I think...) first aid-er, whether they were epipens, or twin jects, or ana kits. 

And the size of the glucagon syringe is 2 mg, only a little bigger than the second syringe in the twin ject. I stand corrected. I also discovered that my glucagon is out of date.


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## MrBrown (Jul 1, 2010)

ajax said:


> And the size of the glucagon syringe is 2 mg, only a little bigger than the second syringe in the twin ject. I stand corrected. I also discovered that my glucagon is out of date.



Interesting, our Glucagon comes in a 1mg reconstitute vial.


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## MMiz (Jul 1, 2010)

MrBrown said:


> Interesting, our Glucagon comes in a 1mg reconstitute vial.


I've only seen it in 1 mg vials.


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## Aidey (Jul 1, 2010)

It's a 2ml syringe though isn't it? Maybe that is what the poster meant.

I have to admit it's been awhile since I looked that closely at a glucagon syringe.


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## EMTtoBE (Jul 1, 2010)

I'm a brand new EMT-B (2 months or so) and I have never heard about the Glucagon pens..but now I do and its good to know ..how often do you come across these in the field?


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## Aidey (Jul 1, 2010)

It's not a pen, it's a kit that includes a vial and a syringe. The glucagon is a powder and has to be reconstituted before it can be used. I've run into several diabetic patients that keep them around. Usually their family/the people they live with are trained in how to use them. I know I've been on a couple calls where the family gave the glucagon and when it didn't work they called 911.


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## EMTtoBE (Jul 1, 2010)

Is it something an EMT-I can do or only Paramedic?


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## usafmedic45 (Jul 1, 2010)

EMTtoBE said:


> Is it something an EMT-I can do or only Paramedic?


Depends on the state.  In Illinois it was part of the EMT-I protocols. Honestly, it should be an EMT-B skill.  I would rather have some dumbass EMT giving glucagon than trying to give oral glucose to someone with marginal protective reflexes.


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## ajax (Jul 1, 2010)

usafmedic45 said:


> Depends on the state.  In Illinois it was part of the EMT-I protocols. Honestly, it should be an EMT-B skill.  I would rather have some dumbass EMT giving glucagon than trying to give oral glucose to someone with marginal protective reflexes.



In Mass it is a paramedic skill, and it is low in the protocol for hypoglycemia. D50 is considered a better option because a) it works even if the diabetic is drunk / intoxicated with something else that their liver is busy filtering, or if they have decreased glycogen stores after running a marathon, etc, b) it doesn't cause the same nausea and vomiting that glucagon does, c) it works faster, and d) it doesn't empty the patients last sugar reserves into their bloodstream, which means it doesn't put them at greatly increased risk for more hypoglycemia later. 

"If no IV access, administer 1-2 mg glucagon." 

Most diabetics will be prescribed a glucagon kit when they are diagnosed - many will not renew the prescription and it will end up out of date. I was told (prior to EMT training) to call 911, give glucagon, and wait. But like I said, glucagon doesn't work for many hypoglycemic episodes. D50 always works (though not always fast enough), unless you screw up your IV.


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## EMTtoBE (Jul 1, 2010)

I live in Vegas and haven't picked up the protocol book yet so wouldn't know lol..and I just started EMT-I class 2 days ago so maybe its something I will learn later on..at least now with the info you guys have been giving I will be one up on the other guys lol thanks


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## usafmedic45 (Jul 1, 2010)

> it works even if the diabetic is drunk / intoxicated with something else that their liver is busy filtering, or if they have decreased glycogen stores after running a marathon



You do realize that the reason why people who are massively drunk or chronic alcoholics are slow to and/or do not respond to glucagon is the same reason why the marathoners don't right?  The "filtering" action of the liver is completely separate from the other functions that are impacted by the administration of glucagon.


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## usafmedic45 (Jul 1, 2010)

> Most diabetics will be prescribed a glucagon kit when they are diagnosed


Care to provide a source for that bit of information?  I would not say most.  I've never seen it listed as a standard of care for a run of the mill diabetic, especially those whose primary problem is chronic hyperglycemia managed by diet or oral medications without any history of hypoglycemia.  



> D50 always works (though not always fast enough), unless you screw up your IV



The only way it does not work fast enough is if you don't have IV/IO access.  Care to elaborate how it might not work "fast enough" in the setting where it is administered? 



> But like I said, glucagon doesn't work for many hypoglycemic episodes.



Actually it's remarkably effective in most.  Once again, care to provide a sourcethat provides the rationale for your assumptions?



> it doesn't cause the same nausea and vomiting that glucagon does



Having given over a hundred doses of glucagon over the past 15 or so years, including massive doses for patients in refractory heart failure or after calcium channel blocker toxicity, I have seen _one_ patient with nausea and vomiting attributable to the administration of glucagon.  

What level of provider are you, just out of curiosity?


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## MMiz (Jul 1, 2010)

I never ran into glucagon kits in the field.  It wasn't until I became a public school teacher that I had at least a student or two each year that had the kit.

As a teacher somehow 30 minutes of training qualifies me to inject students with glucagon, insulin, and Epi.  Our EMT-Basic protocols said that insulin and glucagon were Paramedic skills, while the Epi pen was a BLS skill.


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## EMTtoBE (Jul 2, 2010)

MMiz said:


> I never ran into glucagon kits in the field.  It wasn't until I became a public school teacher that I had at least a student or two each year that had the kit.
> 
> As a teacher somehow 30 minutes of training qualifies me to inject students with glucagon, insulin, and Epi.  Our EMT-Basic protocols said that insulin and glucagon were Paramedic skills, while the Epi pen was a BLS skill.



Hahahahaha its funny how the system works


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## Shishkabob (Jul 2, 2010)

ajax said:


> because a) it works even if the diabetic is drunk / intoxicated with something else that* their liver is busy filtering*





Errrrr.....


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## usafmedic45 (Jul 2, 2010)

Linuss said:


> Errrrr.....


Yeah, I pretty much assumed he was not very good with physiology after that point....


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## MrBrown (Jul 2, 2010)

usafmedic45 said:


> Yeah, I pretty much assumed he was not very good with physiology after that point....



... but, but, but glycogenesis, gluconeogenesis and glyceroneogenesis are all very large words and easily confused with one another


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## ajax (Jul 2, 2010)

> Why might Glucagon injection not work as effectively for treating hypoglycemia while alcohol is in the body?
> Answer:
> Endogenous glucagon is a pancreatic counterregulatory hormone, which is secreted in response to low blood glucose levels. Its main role is to restore low blood glucose levels by generating a ready supply of glucose. It accomplishes this in two ways. Principally, glucagon stimulates the breakdown of liver glycogen stores, converting them to glucose through a process called glycogenolysis. In addition to mobilizing liver glycogen stores, glucagon stimulates hepatic gluconeogenesis through conversion into glucose of gluconeogenic substrates such as alanine, pyruvate, lactate, and glycerol.
> Alcohol can interfere with the process of gluconeogenesis. This occurs during the metabolism of alcohol, in which there is depletion of the supply of pyruvate needed for gluconeogenesis. As a result, alcohol by itself may lead to hypoglycaemia or delay recovery from hypoglycaemia.
> ...



Thanks for making me look deeper into this. I clearly had a layman's explanation, which was unspecific and led me to untrue assumptions. 




usafmedic45 said:


> Care to provide a source for that bit of information?  I would not say most.  I've never seen it listed as a standard of care for a run of the mill diabetic, especially those whose primary problem is chronic hyperglycemia managed by diet or oral medications without any history of hypoglycemia.



Again, I should be more specific. I actually know very little about type two diabetes. I know a hell of a lot about type one, and forget that there are so many people with type two diabetes. My source is conversations with people with type one, which is a relatively large but self selected sample. 





usafmedic45 said:


> The only way it does not work fast enough is if you don't have IV/IO access.  Care to elaborate how it might not work "fast enough" in the setting where it is administered?



When you're friends are also drunk and don't call until you're already having arrhythmia because they don't realize anything is wrong. Not the problem of D50, just the same on scene timing problem that is possible with all medications.  





usafmedic45 said:


> Actually it's remarkably effective in most.  Once again, care to provide a sourcethat provides the rationale for your assumptions?


My assumptions come from my admittedly imperfect knowledge of alcohol and counter regulatory hormone function, and sitting through lots of lectures that make drinking sound like a sure road to severe, untreatable hypoglycemia.




usafmedic45 said:


> Having given over a hundred doses of glucagon over the past 15 or so years, including massive doses for patients in refractory heart failure or after calcium channel blocker toxicity, I have seen _one_ patient with nausea and vomiting attributable to the administration of glucagon.


That's really interesting. Every time I have had a conversation with anyone who has had to use their glucagon kit for severe hypoglycemia they have told me they were nauseated, but at least they were alive. It's not a huge sample size, but probably 20 people. It's interesting that that hasn't been your experience. 



usafmedic45 said:


> What level of provider are you, just out of curiosity?


I am a new basic, and want to be a medic. I am also a type 1 diabetic. I have put a lot of energy into learning about physiology of type 1 from medical journals. Like I said earlier, I have next to no knowledge about type 2, which affects 90% of people with diabetes. I should have made that clear originally.


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## usafmedic45 (Jul 2, 2010)

> When you're friends are also drunk and don't call until you're already having arrhythmia because they don't realize anything is wrong. Not the problem of D50, just the same on scene timing problem that is possible with all medications.



Then that is a problem with your friends, not with D50 and even with a glucagon kit there if they are too blind drunk to realize a problem, how are they going to do anything about it? It's like blaming the airbags when one of your drunk friends crashes into a bridge abuttment.  Just another friendly suggestion, if you're hanging around with people like that, you need to find different friends and as a diabetic you certainly do not need to be drinking to excess.  If you're the DD and someone notices you down, chances are good they are going to realize it's not because you're passed out drunk.  



> sitting through lots of lectures that make drinking sound like a sure road to severe, untreatable hypoglycemia.



Well, if you become a chronic, malnourished alcoholic, it complicates the treatment of hypoglycemia.  It makes glucagon less effective and occasionally ineffective because of a lack of glycogen stores to pull from.  The result is simply that one has to give D50 and some thiamine.  In a couple of severe cases, I've had to put in IO lines or a central line (when I was in the military) to be able to accomplish this.  

Now, if you're prone to hypoglycemia it's not smart to be drinking in the first place but it's not going to produce an intractable hypoglycemic episode simply because you occasionally have a few beers. 



> That's really interesting. Every time I have had a conversation with anyone who has had to use their glucagon kit for severe hypoglycemia they have told me they were nauseated, but at least they were alive. It's not a huge sample size, but probably 20 people. It's interesting that that hasn't been your experience.



A lot of people (myself included) become nauseous simply from the fear associated with needles.  I've never seen a spike in nausea or vomiting associated with glucagon more than some of the other drugs I have given, although it does make sense since it has some effects on the contractions of various parts of the GI tract.  I've noticed a much greater frequency of nausea with narcotics and bronchodilators like albuterol.



> I am a new basic, and want to be a medic. I am also a type 1 diabetic. I have put a lot of energy into learning about physiology of type 1 from medical journals. Like I said earlier, I have next to no knowledge about type 2, which affects 90% of people with diabetes. I should have made that clear originally.



Can I suggest you complete the following classes before going to medic school?
-Anatomy and Physiology I and II
-Pathophysiology
-Any specialized pathophysiology courses (cardiac, etc) that you can find
-General Chemistry I and II
-Organic Chemistry I and II
-Biochemistry
-Epidemiology
-Statistics
They may not seem absolutely necessary,  but they will really help you if you realize that understanding the "why" of what we do is as important, if not more so, than understanding the "what", "when" and "how".


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