D-Mom Blog

The sweet life with a diabetic child

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BAQSIMI Glucagon Nasal Powder FDA Approved – No More Scary Harpoon Needles!

Lilly Diabetes BAQSIMI (glucagon) nasal powder, which received FDA-approval on July 24, 2019, is an alternative to the glucagon emergency kit.

BAQSIMI Nasal Glucagon

Image: Lilly

I had the opportunity to jump on a conference call today with July Settles, US Medical Lead, and Tony Azell, US Vice President, to learn more about Lilly Diabetes BAQSIMI (glucagon) nasal powder, which received FDA-approval on July 24, 2019.

Please note: I am not being compensated by Lilly Diabetes to share this information or to participate in the conference call. I participated because I was interested in the product and had questions.

We have religiously filled our prescription for and carried the traditional “glucagon emergency kit” (the red box) since Q was diagnosed with type 1 diabetes over a decade ago. We keep one kit at school with the nurse, Q carries one kit in her supply bag, and we keep one kit at home in our preparedness kit.

Each year that Q was in elementary and middle school, we met with her teachers to train them on her diabetes management. Each year the teachers’ faces would change, sometimes going white, when I showed them how to use the glucagon kit. Many teachers are afraid of needles. (Get over it, right?!).

In an emergency situation, if a child’s blood sugar is so low that they are having a seizure or are unconscious, would you as a parent or would caregivers and teachers remember all the steps? Would they do it correctly?

(Read “Training School Staff,” an excerpt from my book Kids First, Diabetes Second.)

Nasal glucagon is a game-changer in that it removes the many steps of preparing a glucagon injection.

(Note that in addition to BAQSIMI nasal glucagon, another pharmaceutical company is also developing a glucagon auto-injector.)

BAQSIMI™ (glucagon) nasal powder 3 mg, approved for the treatment of severe hypoglycemia in people with diabetes ages 4 years and above. BAQSIMI is the first and only approved nasally administered glucagon.

Here are my takeaways from the conference call today about BAQSIMI. (And thank you to the other bloggers who were on the call who asked some of these questions.)

BAQSIMI FAQ

  • 6.3 million people use insulin and, for many of them, their biggest concern is about severe hypoglycemia
  • BAQSIMI is approved for people four years old and up.
  • BAQSIMI solves many of the problems of current glucagon: no reconstitution is required, it is stable at room temperature, and it’s small enough to carry in your pocket.

Two Biggest Questions

There were two common questions that Lilly was asked while they were developing their product.

What if I am passed out?

BAQSIMI is passively absorbed, meaning you don’t have to inhale it. The person giving it to you just has to push the plunger until the green line disappears to know that 100% of it has been dispersed.

What if I have a cold?

They studied this, and it didn’t have an effect.

Stability

It can be stored up to 86 degrees. It does not need to be refrigerated. But you need to keep the shrink wrapping on the tube until you use it.

It expires after 18 months.

Availability and Cost

Tony stated that Lilly is “trying to make it affordable and accessible to all people with diabetes who need it.”

Yes, I know, this coming from one of the three insulin-producers who have set list prices crazy high. Insulin pricing is complex, the system is broken, and there isn’t currently a solution.

For people with commercial insurance, there is a copay card available that makes the price $25 for one two-pack or two one-packs. The copay card is good for a year, and you can use it as many times as needed.

If you don’t have commercial insurance, call the Lilly Diabetes Solution Center (1-800-LillyRX) to ask how they can help you access it. Tony says that there is “a solution for any patient in need between patient assistance and the copay card.”

They realize that it’s back-to-school and that parents are filling their glucagon kits now. It takes about a month to get newly approved medicines into retail. You can go to baqsimi.com to sign up for updates about availability. So while you might be able to get a prescription for it, your pharmacy may not have it for a few more weeks.

About that prescription… Doctors are learning about the approval at the same time patients are. Your doctor might not know anything about this. When they write a prescription for it, make sure they write it for “BAQSIMI” or “nasal glucagon,” otherwise you will probably get the traditional glucagon emergency kit (i.e., red kit with the needle). And the pharmacist may have no idea what you are talking about either!

Q&A

Here are answers to some of the questions asked on the call today:

Asthma

The powder is all captured in the nose. It doesn’t go into the lungs so it wouldn’t affect someone with asthma. It is not inhaled; it is “nasally administered.”

Kid vs. Adult Dose

There is no child dose and adult dose like the glucagon emergency kit. Everyone age four and over uses a 3 mg dose.

Glucagon “flips the switch” and tells your body to dump all the sugar available. This doesn’t change “whether you are 150 pounds or 250 pounds.”

Mini Dose

While some people use the traditional glucagon rescue kit as a mini dose, BAQSIMI cannot be used for a mini dose. Rather it is a “rescue dose” only. Lilly’s goal was to create a simple product for rescue. There is not partial dosing. You give all of the powder in the single dose.

Traditional Glucagon Emergency Kit Availability

Lilly has no plans to take the traditional glucagon rescue kit off the market. It is still needed for patients under the age of 4.

Simplicity

You do not need to reconstitute BAQSIMI. There are so many steps in the traditional kit, and it is easy not to do it right. In their studies, Lilly said that there is a 90.9% of people are successful in administering BAQSIMI … without training.

Training

Lilly says that it’s so easy to use that you won’t need an app to tell you how to use it. But they are working on a video, which you will be able to share with caregivers and teachers.

What do you think? Will you be giving BAQSIMI Glucagon Nasal Powder a try?

More Resources on D-Mom Blog

Training School Staff

Diabetes School Supplies

Glucagon Tips

More posts about glucagon

Back to School with Diabetes: Lots of information and links!

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Type 1 Diabetes and Teacher Training

Here are some ways to prepare for the school year when your child has type 1 diabetes including gathering supplies, creating a two-page instruction sheet, and teacher training.

Teacher Training

I remember in the weeks before my daughter Q started kindergarten I was anxious. But sending your child with type 1 diabetes to school is just another instance where parents need to do as much preparation and training as they can to have the confidence to let go on that first morning of school.

I know other parents cried as their child said goodbye, climbed the steps, and walked through the door. For them, it was a simple separation. For us d-moms and d-dads, we wonder if our child will actually make it through the day unscathed. I didn’t cry that first morning, as much as I had a right to, but I had to believe that she would be okay.

Preparing for School

Preparation begins for our family in the weeks before school starts. I begin gathering our diabetes supplies and filling the kits we keep at school to manage her diabetes on a daily basis. I call the assistant principal to set up a training session with staff, which takes place ideally before the first day of school. I fill out any paperwork that the school district needs, update my two-page instruction sheet and take a look at our 504 plan to see if there have been any changes that need to be addressed.

Diabetes Instruction Sheet

The two-page instruction sheet I update each year has two purposes. First, it highlights some of the main points and serves as a guide as I train the staff who oversees my daughter during the day. Second, it’s a quick reference for substitute teachers because it’s always included in their lesson plan (this is specified in our 504 plan).

When Q was in kindergarten, I always brought her to morning line-up. If there was a substitute teacher in her classroom, I walked right up to him/her and said, “This is Q. She has diabetes. Please read over her instruction sheet and don’t hesitate to get the nurse or assistant principal if you have any questions about her care.” Then beginning in first grade, I often gave Q the independence of being dropped off in the car line and didn’t always know if there was a sub. That’s why the two-page instruction sheet became so important.

Our instruction sheet has a photo of Q in the upper right corner so the teacher, sub, or another staff member can easily identify which child she is and note that she requires special attention. The front of the sheet explains low blood sugar symptoms, treatments, and follow-up care, including when to call 911 for severe hypoglycemia and how to use glucagon. The backside describes high blood sugar symptoms and protocols. I also include any other considerations, such as free access to water, the bathroom, and office. In big type at the bottom of both sides are mine and my husband’s cell phone numbers.

Training the School Staff

Staff members I include in the diabetes training session are the assistant principal, classroom teacher(s), art, music and gym teachers, the librarian and, of course, the school nurse. For some, the diabetes training serves as a review. But it’s brand new for the classroom teacher each year.

During the diabetes training, I go over the instruction sheet, point out important considerations in our 504 plan, and demonstrate how to check blood sugars and use glucagon. I admit that I get a little shaky as I demonstrate the glucagon each year because if they have to use it, it’s a serious emergency situation.

If you’re anxious or nervous, understand that the classroom teacher probably is as well. I think the biggest key is to provide information without overwhelming them, but assure them that they can do this and if they have any questions — no matter how small — you are just a phone call away.

More Resources

“Diabetes & Teacher Training” originally appeared on Insulet’s Omnipod Suite D blog, now called Podder Talk. In full disclosure, Insulet compensated me for the content that I created for them, but I am not being compensated for sharing it today.

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3 Little Diabetes Things: Diabetes Forecast September/October 2017

Summary:  Here are three articles in the September/October issue of Diabetes Forecast that I thought you might find interesting. First up is a tip given by yours truly about the low blood sugar kits I make each fall for school. The second and third articles are about glucagon.

I sometimes have a “little” something to say about diabetes…

Diabetes Hacks for Keeping Organized This Fall

A writer from Diabetes Forecast asked if I would share a back-to-school hack and I told her about the low blood sugar kits that I make each August to place in my daughter’s classrooms so that she has easy access to supplies and doesn’t have to go wandering around the school in search of sugar or spend time in the nurse’s office.

I love the graphic they created!

Read “Diabetes Hacks for Keeping Organized This Fall” in Diabetes Forecast.

Also read “Diabetes at School: Low Blood Sugar Classroom Kits.”

Low BG Kit

Image: Diabetes Forecast

New Easy-To-Use Glucagon Products Are Coming

The $100,000 question is how to make glucagon stable. The current six-step process for mixing and injecting glucagon is not only too many steps, but that giant needle makes people who don’t usually see needles kind of frightened (i.e., the teachers that I train every year at school!). Wouldn’t it be awesome if there was an injectable pen similar to an EpiPen? Even if it somehow shot the liquid into the powder and mixed it before injecting. The great thing about the EpiPen is that it, too, has a big needle, but you never see it.

Also, a future artificial/bionic pancreas system might have both insulin and glucagon. Stable glucagon would be needed for that to work.

Read “New Easy-To-Use Glucagon Products Are Coming” in Diabetes Forecast.

Glucagon

Image: Diabetes Forecast

How to Administer Glucagon

But, dude, seriously. Why are there so many steps involved in giving glucagon to someone? This article illustrates the six steps required to mix up and inject glucagon, but what it doesn’t say in step 4 is that it is completely impossible not to have giant air bubbles in the supplied syringe and if I can’t draw it up without having huge air bubbles when I am trying to demonstrate it to teachers, how in the heck am I supposed to draw it up without huge air bubbles in an actual frantic severe hypoglycemic event?!

Read “How to Administer Glucagon” in Diabetes Forecast.

Glucagon Kit

Image: Diabetes Forecast

You Might Also Like…

More 3 Little Diabetes Things posts

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Kids First, Diabetes Second Book: Training School Staff

Training School Staff

When I wrote the school chapter of the book Kids First, Diabetes Second, I think Q was in second or third grade. She has definitely become more independent in her care since then, but I still do the same training and make sure that her 504 plan is followed. In the book I have a list of supplies to stock at school, information about 504 plans, as well as quite a few tips you might find useful to navigate diabetes at school. The section “Training School Staff” is part of the chapter called “School Days.”

Training School Staff

When Q started kindergarten, we contacted the assistant principal during the summer to set up teacher training, and we have continued to do so every new school year. I like to call a meeting every year in the day or two before school starts to train all of the teachers who oversee her throughout the school day. This includes the classroom, art, music, and PE teachers, as well as the librarian, the assistant principal, and the nurse. For some of these staff members, it is a refresher course; but for the classroom teacher, it is always brand new.

During the training session we go over key aspects of her 504 plan, especially the items that pertain to her daily school life, like access to water and the bathroom, checking blood sugar as needed, snacking at scheduled times, and checking blood sugar before important tests. I stress that her supply kit is listed as a separate child on the class roster, so that it is taken (and brought back) on field trips, and any time she leaves the immediate school grounds, such as during a fire drill.

I go over an instruction sheet I create for teachers line-by-line. It includes: the symptoms of low blood sugar; Q’s usual symptoms and the language she uses to describe them; the rule of 15s; low blood sugar treatments; when to use glucagon and to call 911 if it’s needed; and the symptoms of high blood sugar, along with protocol for checking and treating. I point out the three phone numbers they can call to reach my husband or myself, and encourage them to call with any questions. This sheet also includes a photo of Q so she can be easily identified, and it is placed in the lesson plan any time there is a substitute teacher. I put the instruction sheets in plastic page protectors and give one to each teacher, the nurse, and assistant principal.

I then show them the classroom kit, and we decide where each of the kits will be kept. We keep one in the classroom, usually on a shelf near the door, and one in the music room in the supply cabinet because that’s where she would likely take shelter during severe weather or a lock down situation. I go through the entire contents of the classroom kit because teachers might not be familiar with each of the items.

Although Q tests her own blood sugar, I show staff how to load a lancet, lance a finger, and apply blood to the test strip in the meter. If she were unable to think clearly or were shaky, someone might have to test her blood sugar for her. When I demonstrate, I’m always surprised at how much it hurts!

The training session culminates in a demonstration of the glucagon kit. I explain that, while the need for glucagon is not common, it is very important that if she is unconscious or having a seizure, the glucagon must be given immediately and 911 called. Not doing so can result in brain damage or death. This always scares teachers. I assure them it’s like an insurance plan: you need to be prepared just in case, though you may never need it.

I think glucagon makes people nervous for three reasons. First, they are nervous because it’s used in an emergency situation for the child, and they are afraid they won’t remember what to do under pressure. Second, they are afraid that if they do it wrong they will do more harm than good. And third, that needle is really huge!

When training school staff, I try to be as calm and reassuring as possible. I show them what the plastic case looks like and where they can find one in an emergency (in Q’s d-supply bag, in the classroom kits, in the main office). I show them exactly how to use the kit and remind them to have someone call 911. After horrifying the teachers with the glucagon instruction, I assure them, once again, that they will get the hang of things even if they are feeling overwhelmed with the depth of information, and I tell them not to hesitate to reach out to the nurse, or assistant principal, or me with any questions.

After the regular staff leave, I stay a bit longer for more in-depth training with diabetes personnel listed on Q’s 504 plan, which include the school nurse and assistant principal. With these staff I go into more detail about checking ketones and blood sugar, making sure she gets insulin for the food she actually eats at lunchtime, and how to use her insulin pump.

Kids First Diabetes Second Book

Learn More

If you’d like to learn more about the book, you can read more on the Kids First, Diabetes Second book page. It’s available widely in print and as an eBook from book sellers such as Barnes & Noble, Amazon.com, and IndieBound. And if you do read it and find it to be a valuable resource, I would greatly appreciate if you could write a review on any of the online retail sites. Thanks!

Disclosure: This post contains affiliate links to booksellers.

Further Reading…

More posts about glucagon

Back to School with Diabetes: Lots of information and links!

I have an entire chapter about school in my book Kids First, Diabetes Second.

Read more posts about Diabetes at School.

Please remember that I never give medical advice. Ask your endocrinologist or pediatrician for advice about your own child. Make your own informed decisions for your own child.

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Lowest of Lows

Please remember that I never give medical advice. Ask your endocrinologist or pediatrician for advice about your own child. Make your own informed decisions for your own child.

Q has high and low blood sugars all the time. It’s just part of life with diabetes for an active kid. Few lows or highs rattle my cage because this isn’t our first rodeo. But this particular night, I was surprised at how quickly Q’s BG could drop.

At bedtime snack Q’s CGM showed about 175 with two arrows down. By bedtime she was right around 100. A few minutes after lights out her CGM buzzed that it hit her low threshold (85 mg/dL) so I had her drink a juice box.

I laid down and turned on the TV and a few minutes later Q was at my bedside, glossy eyed.

She said, “I feel weird. I haven’t felt like this since I was little. I can’t focus on anything and I can hear my heartbeat in my ears.”

I said, “You must be pretty low. Let’s get you back in bed and we’ll check your blood sugar.”

I was not expecting to see 31 mg/dL on her meter!

Low Blood Sugar

Low Blood Sugar

Low Blood Sugar

This actually ties for the lowest low she’s ever had. A few years ago she came inside from playing in the snow (pre-CGM days) feeling low, but walking and talking and ready to get right back out there.

Until that point I had always assumed that at that number a child would be unconscious and in need of glucagon and a 911 call.

I snapped into action reaching for the supplies in her night stand organizer. And there was nothing that I needed in that moment. No glucose gel. The glucagon was expired.

There was a brick of juice boxes on the floor by her nightstand, but the first one hadn’t seemed to help.

Low Blood Sugar

I called down to my husband to grab a glucose gel. I asked him to give her the gel and sit with her. I had noticed that she had 1.65 units of insulin on board (IOB) and was afraid that her BG was going to stay stubbornly low or drop further. I used my phone to look up mini glucagon in case our fast acting carbs didn’t help, she couldn’t stomach ingesting more carbs, or in case she vomited.

And of course I snapped a few pictures while I waited a few minutes to check her again.

I had my husband go back downstairs for a box of bunny gummies and the new package of glucose gel.

While she ate a package of bunny gummies, I sent my husband down to grab more test strips, a glucagon kit that wasn’t expired, and some syringes.

Low Blood Sugar

Low Blood Sugar

At hearing the word “syringe” Q had a look of fear. It’s been so long since she was on multiple daily injections (MDI) that she balks at the thought of getting just one.

She said, “What I wouldn’t give for some peanut butter crackers.”

I rechecked her blood sugar and she was in the 70’s. I called for my husband to come walk her down the stairs, just in case she got wobbly, so that she could have some peanut butter crackers. (The “rule of 15’s that we typically follow states to have a snack with protein after treating a low if it will be several hours until the next meal.)

I didn’t want cracker crumbs in her bed!

Of course during this my son was awoken, which nullified getting both kids to bed early that night!

I knew that after having a juice box, a glucose gel, bunny gummies, and finally peanut butter crackers, she would rebound. When I checked her after a bit she was 183, with the CGM saying 175 with two arrows up.

Low Blood Sugar

But in the grand scheme of things I’d rather deal with a high blood sugar in the night if it meant we averted a crisis.

When I checked on her at 10:30 pm she was 233. I gave the correction that her pump suggested. And I hoped that that’s that and we would all sleep the rest of the night.

If there are any takeaways from this experience they might be:

(Remember, this is not medical advice but was my thought process in treating this severe low.)

  • Stay calm.
  • Gather the supplies I might need to treat this low. (In this case I gathered test strips, juice boxes, bunny gummies, glucose gel, glucagon, and regular syringes.)
  • Try to determine why this severe low is occurring (for example exercise or illness) because it might determine treatment.
  • Determine if there is active insulin which could continue to pull the blood sugar down.
  • Think about my options and weigh what might have the best results. (In this case we gave a series of fast acting carbs followed by a protein snack.)
  • Monitor blood sugar by finger stick in conjunction with CGM, if available.

I will say that we tend to rely on CGM for alerting us to highs and lows, hopefully before they get too high or too low. But sometimes with a rapidly changing blood sugar the CGM just can’t keep up. (Maybe this is why there is a disclaimer screen on the new pediatric version of Dexcom’s CGM receiver.) I never would have suspected that Q’s BG would have been 31 mg/dL as it was a pretty laid back night at home with no dance class or evening activity. Q felt her low. In fact she felt terrible. And she had the wherewithal to come tell me. It’s important, even for PWD’s using a CGM, to listen to how your body feels and to trust it.

Please remember that I never give medical advice. Ask your endocrinologist or pediatrician for advice about your own child. Make your own informed decisions for your own child.

All images are copyright D-Mom Blog and D-Mom Media and may not be copied or reproduced without express written permission.

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Tips For Getting Glucagon And EpiPens With Longer Expiration Dates

Please remember that I never give medical advice. Ask your endocrinologist or pediatrician for advice about your own child. Make your own informed decisions for your own child.

glucagon epipen expiration

 

I think everyone has been stocking up on glucagon and epipens for the school year because I’ve heard lots of grumbling among d-moms and allergy moms about receiving glucagon and epipens that expire short of a year.

I personally like to send in glucagon kits and epipens that are good for the entire school year so that I don’t have to think about it again.

On top of the inconvenience of receiving ones with short dates, you will spend more money replacing them more often.

Here are some tips on getting glucagon and epipens from the pharmacy that don’t expire within 12 months:

1. When you refill the prescription, tell them you won’t accept any that aren’t good for at least 12 months. Knowing ahead of time can help save frustration for you and the pharmacist. Many pharmacies have a box to leave a note for the pharmacist when using their app or online refill service.

2. ALWAYS look at it before leaving the pharmacy counter and insist it’s at least one year. If you pay and walk away, you may not be able to return or exchange it.

3. They may have to order new ones in and that may take a day or two. Because of this, try not to wait until the very last moment when you need them right now.

4. If they won’t provide you with glucagon kits or epipens that are good for at least 12 months, get a new pharmacy.

Tip: Save those expired glucagon kits. You can use them to train teachers and staff at the beginning of the next school year.

You Might Also Like…

More posts about glucagon

More posts about diabetes at school

{Diabetes at School} Glucagon Tips

All images are copyright D-Mom Blog and D-Mom Media and may not be copied or reproduced without express written permission.

The Dutch House (and Diabetes)

The Dutch House, written by Ann Patchett and narrated by Tom Hanks, includes a main character who is diagnosed with and lives with type 1 diabetes. Here are my thoughts on the book, in general, and the author’s treatment of diabetes.