Ask D’Mine: Type 1 Kids and Birthday Parties, How Glucagon Works

Ever wish there was someone to ask all those pressing, confounding, and disconcerting questions about life with diabetes? Someone who really “gets it”? Well, now there is!

If you haven’t discovered our diabetes advice column Ask D’Mine yet, now is your chance to jump in!  This Saturday series is hosted by veteran type 1, diabetes author and community educator Wil Dubois.

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

Laura from Arizona, type 3, sends us this reach-for-the-Kleenex tale: I have a question about what is the best site for foods for an 8-year-old girl who was just diagnosed last week. I am sorry, I am just so angry! I grew up caring and watching over my father who has had type 1 for 52 years (he is amazing), but when this happened to my little sweetheart niece I about died. She was doing wonderful in this past week, started giving her own injections, guessing her numbers while she checked her blood—just amazing to see.

But she just went to her first birthday party over the weekend and could not eat chips, dips, cake or drink the punch and sodas like all the other kiddos were doing. This is when it all hit her. She has changed, she has to think about what she eats, she has to plan ahead… Her 9th birthday is right around the corner and she told her mom that she does not want to have a party. I need to find a place where we can see the nutrition info; and isn’t there some way to make a yummy birthday cake for her?!? I want her to have an amazing birthday, one that she deserves to have. I will be forever grateful for any information you can give me.

Wil@Ask D’Mine answers: Your niece sounds like a trooper-and-a-half! She’s a week out of dx and doing her own injections, checking her blood, and thinking about her food. Waaaaaaaaaaaay to go, kiddo! As is often the case, the little persons with diabetes handle this mess better than their families do. (Worst job in the world alert: parent of child with diabetes, especially if you do not already have diabetes yourself.)

So when it comes to our littlest brothers and sisters I don’t think anyone will flame me for saying that your first stop should be the Children with Diabetes community. Their food and nutrition section should give you everything you need and more.

As you’ll get all the specifics there, I’m going to give you some more global thoughts here. Bear in mind that half the endos out there will be sending me letter bombs after reading this, and that 49% of the mothers of type 1 kiddos will be buying Wil voodoo dolls on eBay… But…

I think your niece should go to parties. And when she’s there I think she should eat chips, dips, and cake. I do draw the line at the punch and soda, however. Our kind simply cannot handle liquid sugars. Ever. Well, not recreationally, anyway. As a treatment for  low blood sugar it’s another thing altogether. Now, back to the chips, dips, and cake. She’ll probably need to limit her portions some. She’ll need to pack extra insulin, of course. She should have a low-carb breakfast before heading to the party, of course.

In other words, yes, your family needs to take sensible safety precautions, but those medical needs must be balanced with the social needs of the child. Will the party make a train wreck of her blood sugar? Yeah, probably. But how often do these kinds of parties happen? A couple times a year? And how often is a type 1 kiddo’s blood sugar a train wreck even when the family does every frickin’ thing right? Yeah. About once per week.

I think you just need to take parties in stride. As for her own party, I’m partial to Splenda for making lower-carb yummy birthday cakes. Now remember that at least half the blood sugar impact of the cake is gonna be in the flour. Not much you can do about that, but if you have a cake recipe you like, you can substitute the sugar for Splenda, and drop the blood sugar impact of a slice quite a bit. Splenda has a freaky-looking fake snow consistency in the measuring cup and weighs next to nothing, but it’ll work fine and, unlike some other faux sugars, can be used in baking. The cake will have the same flavor and consistency you’re used to, it just won’t brown quite right. But you’re going to cover it with icing anyway, so no one will know. And, of course, you can use Splenda in the icing, too.

So, Laura, no anger. No grief. Your niece is, and will continue to be, the sweetheart she always was. Now, go put on your damn apron, break out the Splenda, and make your niece the yummiest diabetes-friendly cake of all time.

And for the rest of you, today’s stock quote for Kimberly-Clark, makers of Kleenex, can be found here.

Ariel from New Mexico, type 3, asks: How long does glucagon take to work? I had read somewhere that it takes 20 minutes! I think if, God forbid, I have to give my four-year-old daughter a shot and she stayed unconscious for 20 minutes I’d die of a heart attack myself!

Wil@Ask D’Mine answers: Wow. What a great question. Glucagon, for those of you who don’t know or forgot, is a drug used to intervene in near-death experiences caused by severely low blood sugar. You know, I’ve carried glucagon with me for years, trained dozens of people (including my own son Rio, right after his 5^th birthday) to use it, but never once gave the action time a single thought.

It’s instant, right? Well, no. Apparently not.

But before we get into the issue of response time, let’s do a quick review. Glucagon is a hormone that causes the liver to release its inventory of sugar. It’s the break-glass-in-case-of-emergency drug of last resort for severe hypoglycemia. It’s an unstable compound so it must be mixed right before use. Glucagon kits are made by both Eli Lilly under the name of Glucagon Emergency Kit and Novo Nordisk under the name GlucaGen Hypo Kit. As far as I can tell, the only real difference is that Lilly’s comes in a red box and the Novo kit comes in an orange box. Both have a prefilled syringe of saline and a vial of glucagon powder. To get it ready to use you must remove the syringe and vial from the case, un-cap the needle, un-cap the vial, inject the saline into the vial, mix it around, then draw it back into the syringe. What could be easier or faster?

Oh wait. Did I forget to mention that this procedure needs to be done by a presumably freaked-out type 3 whose loved one is out cold on the floor from low blood sugar? Right. Glucagon is used when it’s too late for glucose tabs, gels, or Skittles. Glucagon is used when lows are so bad the PWD is unresponsive. The procedure above takes less than a minute, but I’d wager it would be one of the longest minutes of a type 3’s life.

In fact, I know of one tragic story from the northern part of our state. A panicked mother injected just the saline into her unconscious son. She forgot to do the whole inject, mix, draw thing.

He died.

After I heard about that, I started all my glucagon carrying families on regular fire drills, having them practice with expired kits (minus final injection, of course). The PWDs generally have a great time simulating a low-blood sugar collapse. Oh, speaking of expired, these kits don’t last forever and I’d bet that more than half of you are carrying expired ones. Make sure your damn glucagon kit hasn’t expired. Go check.

Right now.

I’ll wait here for you.

OK, so how long does it take to bring you back from the almost-dead? “One minute” is quoted a lot on the web, but it’s false. And I think I know the source of the confusion. The physician prescribing sheet for Lilly’s kit also lists another use for glucagon—and you’ll love this—as a muscle relaxant for colon exams.

Yes. You always suspected that diabetes would f – -  What? Oh. Well, my PG-13 rating won’t allow me to clearly spell out what I’m thinking, but I’m sure you can figure out what I’d say next if I could.

Anyway, when injected intravenously, the onset of glucagon as a muscle relaxant is one minute. But nowhere in the scientific literature could I find anything close to a one minute action time for revival from a bad hypo. I think someone, somewhere along the line, saw the colon exam chart, didn’t read carefully, and put the one minute time on the web. Since then it’s just been repeated again and again. Copy, paste. Copy, paste. Copy, paste.

This is why you should never believe anything you read on the web.

Oh. Except here at DiabetesMine, of course.

In point of fact, the two pharma companies that make glucagon are vague about the action time for hypo revival. The sheet for docs from Lilly says, “An unconscious patient will usually awaken within 15 minutes following the glucagon injection.”

Ah.

Usually awaken.

Within 15 minutes.

How comforting.

Novo’s glucagon page states their product works “within about 10 minutes.”

Ah.

Within about.

Very precise.

So is the Novo product five minutes faster, or is this just marketing BS? I’d still put my money on the only difference between the two being the color of the case.

More fun glucagon tips: Glucagon makes most people puke. So after you stab your loved one, roll them on their side (for complex anatomical reasons, the left side is preferred), so that they don’t choke when they throw up. Oh. Unless your diabetic loved one has collapsed on an expensive oriental rug in which case the procedure is stab, drag, roll.

Then call 911. Severe lows, like earthquakes, can have aftershocks. If you just emptied your liver of sugar, you have no more reserves. A second bad low could be a one-way trip to the great beyond, so glucagon use requires a visit to the ER until things stabilize.

Oh, and according to the info sheet in the kits, if your PWD is still out cold after 15 minutes, you can give a second shot. For kids, a kit holds enough for two shots. For adults, you are out of luck unless someone has a second kit handy.

Some people worry about what if? What if the PWD is lights-out because their blood sugar is too high rather than too low? The official advice is to give the shot anyway. Highs take quite a bit of time to kill you. Hours. Severe lows can kill your pretty damn quick. Minutes count.

Where to inject? Several training manuals for school-based personnel are advocating injecting into fat, just like insulin, but the microfilm-sized instructions from both pharma companies advocate straight into muscle of the arm, butt, or thigh. Would that hurt? Hell yeah.

But don’t worry, type 3s. If you’ve broken out the glucagon we’re unconscious anyway.

We’ll forgive you an achy butt for saving our asses.

Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.