Glucagon

Evidence does not rule out use of glucagon by people with type 2 diabetes

We read with great interest the learning module on hypoglycaemia in the Spring 2001 issue. However, we were concerned about the statement, 'Glucagon should not be used in those with type 2 diabetes because it will stimulate further pancreatic insulin release'. This issue is not as clear as the article would suggest, and may be extrapolation of theoretical information.

Evidence for the use of glucagon in diabetes patients on oral therapy is sparse, but we would like to draw attention to Taylor et al (1978) whose study specifically addressed this question. In six patients with type 2 diabetes treated with diet alone and taking chlorpropamide 250mg/day, parenteral glucagon raised blood glucose concentrations, producing a greater and more prolonged increase when given intramuscularly than intravenously. Hypoglycaemia did not occur in any subject.

We would be grateful if the authors of the learning module could supply any references supporting their statement. If the balance of evidence does not support the statement, we feel that it is important that this should be corrected as otherwise an important immediate treatment option for hypoglycaemia might be neglected.

Jonathan Levy, Consultant Physician

Janet Sumner, Diabetes Specialist Nurse

Oxford

Taylor JR, Sherratt HS, Davies DM (1978) European Journal of Clinical Pharmacology 14(2): 125-7

AUTHOR'S RESPONSE: Uncertainty in guidelines reflects lack of specific evidence

There is virtually no published evidence as to the effect of glucagon in sulphonylurea-induced hypoglycaemia, either benefical or adverse. The controversy over this issue is reflected in the variance of published guidelines, either advocating or warning against its use in this situation. The data sheet for Glucagen, the most commonly prescribed glucagon kit, lists phaeochromocytoma and glucagon sensitivity as the only contraindications to its usage, but it is licensed only for the treatment of insulin-induced hypoglycaemia. Given this uncertainty, clinicians using glucagon for the treatment of sulphonyulurea-induced hypoglycaemia must be aware of the potential risks and may wish to use safer alternative.

Peter Hammond

Consultant Physician, Harrogate District Hospital

Clarification needed on issues concerning Muslim patients

The editorial by Dr Qureshi, Management of Diabetes During Ramadan, which appeared in a recent issue of this journal (3(2): 36-7) was useful.

However, I am uncertain about two issues raised:

First, point 7 states that 'onion and garlic are hypoglycaemic foods'. Are there any references to support this because I have never seen it before.

Second, point 9 states that using initials rather than full first or middle names would be offensive. How true or relevant is this? I have never had problems when initials have been used on appointment letters, for example.

Rupindar Sahota

Community Diabetes Dietitian

Haunslow & Spelthorne Community Trust

AUTHOR'S RESPONSE: Debate on hypoglycaemic foods is open

I am grateful to Rupindar Sahota, particularly as she is a community dietitian, for raising an important issue -- whether onion and garlic are hypoglycaemic foods or not.

I clearly remember reading in a book on alternative medicine, which I was reviewing for the Journal of the American Medical Association, that karela (an Indian vegetable), onion and garlic are hypoglycaemic foods. Onion and garlic are widely and excessively used in Indian, French, Italian and Greek diets. The book put forward a reason for this: Indian, Italian and Greek sweets are sweeter than English sweets and lead to a high post-prandial blood sugar. Onion and garlic are used culturally to lower the raised blood sugar so as to restore the balance.

Many cultural traditions are only explained in scientific literature in English, when health professionals from that culture learn the scientic jargon and get the opportunity to write in English, the international language.

So far, I have not been able to find the particular reference. However, I shall look more extensively for any references to prove or disprove the described hypoglycaemic properties of onion and garlic. Learning is a mutual process; therefore, would Rupinder Sahota and other readers please join the search to clarify the final view on this important clinical issue in diabetes care. I keep an open mind and am always willing to learn. As evidence accumulates for or against a particular issue, scientific health professionals modify their views in accordance. Let us all use the Letters column of Diabetes and Primary Care to investigate this practical point of interest to doctors, nurses and dietitians.

Taking the second issue, one's name is one's most important asset. Muslim, Hindu and Sikh names have a strong religious symbolism. For example, one can forecast that Rupinder is a Sikh name and Bashir Qureshi is a Muslim name. Using initials instead of the first or middle name is an English secular custom, which probably arose in the days of the British empire. In England, when people are offended, Muslims, Hindus and Sikhs, as with the English, tend to be stoic. They opt for either ethnic segregation or for tolerance. My initials are BA (Bashir Ahmed -- religious Muslim names). I jokingly tell my English colleagues that these stand for 'Best Available'. Tolerance and a sense of humour are hallmarks of our British society.

Bashir Qureshi

GP, London and Provost of the RCGP

Expert Witness in Transcultural Medicine and Issues

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