The use of glucagon during upper gastrointestinal endoscopy

Provider-reported use of butylscopolamine in gastrointestinal endoscopy in Germany

Introduction The anti-cholinergic agent hyoscine-N-butylbromide (HBB) is used in gastrointestinal (GI) endoscopy to decrease motility and facilitate endoscopic procedures. Data from clinical studies to support this practice is limited especially for therapeutic procedures. Likewise, patterns of use among endoscopist are largely unclear. This study sought to assess usage of HBB among German-speaking endoscopists. Material and Methods We conducted an anonymous online survey among endoscopists in German-speaking countries. Results A total of 207 physicians participated in the survey. The majority (76.9%) were experienced endoscopists and 92.3% of respondents use HBB at least occasionally during procedures. The reported median stated frequency of HBB use varied greatly between different types of procedures and increased with the complexity of the procedure being performed. HBB was rarely used in diagnostic esophagogastroduodenoscopies (EGD) (median stated frequency 1% of procedures), while use frequency was significantly higher in EGD with endoscopic mucosal resection (EMR) (10%; p=0.002) and EGD with endoscopic submucosal dissection (ESD) (20%; p<0.001). Similarly, use frequency during diagnostic colonoscopy was lower (5%) compared to colonoscopy with EMR (20%, p=0.005) or ESD (42.5%, p<0.001). The highest use frequency was reported for ERCP (50%). The most frequently stated reason to use HBB was facilitation of the procedure (80.6%) followed by increasing diagnostic yield (58.3%). Conclusion German-speaking endoscopists commonly use HBB, most frequently to facilitate complex therapeutic procedures. Given there is almost no data supporting HBB use in therapeutic endoscopy, we suggest that more research is needed to evaluate benefits and risks of this practice.

Antispasmodic drugs in colonoscopy: a review of their pharmacology, safety and efficacy in improving polyp detection and related outcomes

Antispasmodic drugs are cheap, effective and generally safe. They may improve outcomes in colonoscopy, however their use has not been consistent or widespread. This manuscript reviews the three most commonly used antispasmodics in colonoscopy, namely, hyoscine butylbromide (and related ammonium compounds), glucagon and peppermint oil. The pharmacology, action and safety of the agents, as well as the evidence for them improving colonoscopic outcomes will be discussed. In addition to polyp detection, other colonoscopic outcome endpoints of interest include cecal and ileal intubation, and patient comfort. The drugs studied were all found to be effective gastrointestinal antispasmodics with good safety profiles. There is insufficient evidence to conclude whether antispasmodics improve cecal intubation rate, predominantly because the baseline rates are already high. Antispasmodics probably have efficacy in reducing cecal intubation time especially in those with marked colonic spasm. Antispasmodics do not offer significant benefit in polyp detection or improving patient comfort during colonoscopy. Future studies should focus on inexperienced colonoscopists as well as those with marked colonic spasm, in whom the greatest benefit seems to lie.

The nature of amyloid-like glucagon fibrils

Protein aggregation and formation of amyloid fibrils is a phenomenon usually associated with proteotoxicity and degenerative diseases, such as type 2 diabetes, Alzheimer's disease, and prion diseases. However, several protein and peptide hormones are known to have a high propensity to form amyloid-like fibrils in vitro raising concerns about safety and stability of pharmaceutical protein solutions. Comprehensive understanding of the aggregation mechanisms is an important prerequisite to the design of strategies to prevent fibril formation. Detailed kinetic, spectroscopic, and morphological studies have revealed that glucagon can form several types of fibrils that differ at the level of molecular packing of the peptide. Each type forms through distinct nucleation-dependent aggregation pathways influenced by solution conditions and can be self-propagated by seeding. An increasing number of functional amyloid-like structures have been discovered in nature, and it has recently been proposed that an amyloid-like state of glucagon may be utilized by the pancreatic α-cells as in vivo storage form. This article reviews the current state of our knowledge about the nature of the different types of amyloid-like glucagon fibrils, the mechanisms by which they form, and discusses implications for formulation strategies and the safety of glucagon pharmaceuticals.

A prospective, double-blind trial of somatostatin analog (octreotide) versus glucagon for the inhibition of small intestinal motility during endoscopic retrograde cholangiopancreatography

BACKGROUND

Glucagon is effective when used as an antimotility agent during ERCP, but at high doses it may cause nausea and vomiting. Octreotide acetate, a long-acting synthetic analog of somatostatin, inhibits contractility of the small intestine and is generally well tolerated. The purpose of this study was to determine if octreotide given prior to ERCP reduced the requirement for glucagon and enhanced patient tolerance for the procedure.

METHODS

Patients undergoing ERCP (n = 100) performed for a variety of indications (but not sphincter of Oddi manometry) were randomly assigned to receive normal saline solution or octreotide at a total dose of 25 micrograms, 50 micrograms, or 100 micrograms diluted in normal saline solution prior to the procedure. Glucagon was subsequently administered (as needed, to inhibit intestinal motility) by endoscopists who were blinded to the test substance given prior to the procedure.

RESULTS

For all treatment groups, the dose of glucagon required to inhibit intestinal motility in patients who received octreotide prior to the procedure was not significantly different from the dose administered to patients who received normal saline solution. There was no significant difference in the incidence of nausea and vomiting when individual test groups were compared to the control group.

CONCLUSION

Nausea and vomiting after ERCP were uncommon in all treatment groups. Administration of octreotide prior to ERCP did not significantly reduce the dose of glucagon required to inhibit intestinal motility. Tolerance for ERCP was similar for patients given octreotide when compared with those given glucagon to inhibit small intestinal motility.

A randomized study comparing glucagon and hyoscine N-butyl bromide before endoscopic retrograde cholangiopancreatography

BACKGROUND

This study tried to resolve whether glucagon is a better premedication for endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

We first measured the basal blood sugar and amylase levels. Then an endoscope was placed in the duodenum without premedication, and basal pulse and duodenal peristaltic rates were measured. ERCP began after studied subjects were randomly premedicated with either 1 mg glucagon (n = 38) or 40 mg hyoscine N-butyl bromide (n = 36) intravenously. Ten minutes later the variables were measured again.

RESULTS

Glucagon elicited hyperglycemia whereas hyoscine N-butyl bromide manifested an anticholinergic effect. No difference was found between these two groups with regard to the necessary interval for ERCP (20.6 +/- 14.1 min versus 21.4 +/- 14.7 min; NS) or the success rate for cholangiopancreatography (92.1% versus 91.7%; NS). Neither hyperamylasemia nor pancreatitis was preventable when glucagon was used.

CONCLUSIONS

The two premedications appear equally effective in the performance of ERCP.

The action of porcine glucagon on the motility of the canine duodenum and jejunum

1 Intravenous bolus doses of porcine glucagon of 0.001-0.05 mg kg-1 caused intense stimulation of the duodenum and jejunum of the dog. 2 Intravenous infusion of porcine glucagon at 0.025-0.05 mg kg-1 h-1 caused similar stimulation. In both cases the stimulation was phasic in nature. 3 Stimulation of the duodenum and jejunum following glucagon was accompanied by a decrease in frequency of the intestinal basic electrical rhythm (BER). No change was seen in the intervals between successive periods of phase III motor activity.

Comparison of glucagon, atropine, and placebo as premedication for endoscopy of the upper gastrointestinal tract

The effects of 0.5 mg glucagon and 0.5 mg atropine given intravenously as premedication in upper gastrointestinal endoscopy have been examined and compared to those of placebo (0.9% NaCl) in a double-blind study involving 36 patients and 1 endoscopist. The results showed no difference between atropine, glucagon, and placebo with regard to vomiting, opening of the pylorus, feeling of discomfort, or the success of the examination. Glucagon significantly reduced peristalsis compared with both atropine (p less than 0.01) and placebo (p less than 0.01). The reflux was also significantly reduced by glucagon compared with both atropine (p less than 0.01) and placebo (p less than 0.01). No difference was found between glucagon and atropine with regard to secretion, but both drugs reduced the secretion compared with placebo (p less than 0.05). Glucagon also reduced the secretion of mucus compared with placebo (p = 0.05). No adverse effects occurred.