Should Gluc-Be-Gone? Revisiting Glucagon Use in Beta-Blocker Toxicity

Glucagon has historically been considered the agent of choice for management of hypotension and bradycardia due to beta-blocker toxicity, largely based on its ability to bypass beta-adrenergic receptors and increase intracellular cyclic AMP. Despite this theoretical benefit, glucagon use is associated with considerable limitations that challenge its role as first-line therapy. Operationally, glucagon requires a substantial number of vials to prepare a continuous infusion, often straining or even exhausting institution-wide supply. Clinically, published evidence supporting glucagon's efficacy is limited and inconsistent, primarily available as case reports, small observational studies, and animal data. In the 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest of Life-Threatening Toxicity Due to Poisoning, glucagon use for bradycardia or hypotension was designated a Class 2a recommendation, while high-dose euglycemic insulin therapy received a Class 1 recommendation. Glucagon remains a first-line recommendation in health systems and Poison Control Centers across the country. Should alternative treatments be prioritized earlier in acute management? This presentation will explore the mechanism of action for glucagon and high-dose euglycemic insulin therapy, review the available literature for beta-blocker toxicity management, and discuss practical and operational considerations relevant to pharmacists including medication preparation, adverse effects, and resource utilization.