Glucagon adjuvant treatment

 Q: 52 years old female admitted to ICU with an intentional overdose of metoprolol. IV glucagon has been planned as an antidote. Which one adjuvant treatment may be helpful to counter the side effect of glucagon?

Answer: antiemetic 

Despite weak evidence,  glucagon is frequently getting used in beta-blockers overdose. Glucagon should be given as a slow bolus followed by a continuous infusion. Glucagon activates adenylate cyclase causing an increase in adenosine 3'-5'-cyclic monophosphate (cAMP). Elevations in cAMP increase the intracellular calcium which augments contractility. 

Glucagon is known to induce vomiting. It may be helpful to add an antiemetic like ondansetron.

#toxicology

References:

1. Bailey B. Glucagon in beta-blocker and calcium channel blocker overdoses: a systematic review. J Toxicol Clin Toxicol 2003; 41:595. 

2. Boyd R, Ghosh A. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon for the treatment of symptomatic beta blocker overdose. Emerg Med J 2003; 20:266.

3. Ranganath L, Schaper F, Gama R, Morgan L. Mechanism of glucagon-induced nausea. Clin Endocrinol (Oxf). 1999 Aug;51(2):260-1. doi: 10.1046/j.1365-2265.1999.00845.x. PMID: 10469001.