Baqsimi
(glucagon)Dosage & Administration
Baqsimi Prescribing Information
BAQSIMI™ is indicated for the treatment of severe hypoglycemia in adult and pediatric patients with diabetes ages 4 years and above.
Important Administration Instructions
BAQSIMI is for intranasal use only.
Instruct patients and their caregivers on the signs and symptoms of severe hypoglycemia. Because severe hypoglycemia requires help of others to recover, instruct the patient to inform those around them about BAQSIMI and its Instructions for Use. Administer BAQSIMI as soon as possible when severe hypoglycemia is recognized.
Instruct the patient or caregiver to read the Instructions for Use at the time they receive a prescription for BAQSIMI. Emphasize the following instructions to the patient or caregiver:
- Do not push the plunger or test the device prior to administration.
- Administer BAQSIMI according to the printed instructions on the shrink-wrapped tube label and the Instructions for Use.
- Administer the dose by inserting the tip into one nostril and pressing the device plunger all the way in until the green line is no longer showing. The dose does not need to be inhaled.
- Call for emergency assistance immediately after administering the dose.
- When the patient responds to treatment, give oral carbohydrates to restore the liver glycogen and prevent recurrence of hypoglycemia.
- Do not attempt to reuse BAQSIMI. Each BAQSIMI device contains one dose of glucagon and cannot be reused.
Dosage in Adults and Pediatric Patients Aged 4 Years and Above
The recommended dose of BAQSIMI is 3 mg administered as one actuation of the intranasal device into one nostril.
If there has been no response after 15 minutes, an additional 3 mg dose of BAQSIMI from a new device may be administered while waiting for emergency assistance.
Nasal Powder:
- 3 mg glucagon: as a white powder in an intranasal device containing one dose of glucagon
Pregnancy
Risk Summary
Available data from case reports and a small number of observational studies with glucagon use in pregnant women over decades of use have not identified a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. Multiple small studies have demonstrated a lack of transfer of pancreatic glucagon across the human placental barrier during early gestation. In a rat reproduction study, no embryofetal toxicity was observed with glucagon administered by injection during the period of organogenesis at doses representing up to 40 times the human dose, based on body surface area (mg/m2) (see Data).
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Data
Animal Data
In pregnant rats given animal sourced glucagon twice-daily by injection at doses up to 2 mg/kg (up to 40 times the human dose based on body surface area extrapolation, mg/m2) during the period of organogenesis, there was no evidence of increased malformations or embryofetal lethality.
Lactation
Risk Summary
There is no information available on the presence of glucagon in human or animal milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. However, glucagon is a peptide and would be expected to be broken down to its constituent amino acids in the infant's digestive tract and is therefore, unlikely to cause harm to an exposed infant.
Pediatric Use
The safety and effectiveness of BAQSIMI for the treatment of severe hypoglycemia in patients with diabetes have been established in pediatric patients ages 4 years and above. Use of BAQSIMI for this indication is supported by evidence from a study in 48 pediatric patients from 4 to <17 years of age with type 1 diabetes mellitus. [see Clinical Studies ].
The safety and effectiveness of BAQSIMI have not been established in pediatric patients younger than 4 years of age.
Geriatric Use
Clinical studies of BAQSIMI did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Limited clinical trial experience has not identified differences in responses between the elderly and younger patients.
BAQSIMI is contraindicated in patients with:
- Pheochromocytoma because of the risk of substantial increase in blood pressure [see Warnings and Precautions ]
- Insulinoma because of the risk of hypoglycemia [see Warnings and Precautions ]
- Known hypersensitivity to glucagon or to any of the excipients in BAQSIMI. Allergic reactions have been reported with glucagon and include anaphylactic shock with breathing difficulties and hypotension [see Warnings and Precautions ]
Substantial Increase in Blood Pressure in Patients with Pheochromocytoma
BAQSIMI is contraindicated in patients with pheochromocytoma because glucagon may stimulate release of catecholamines from the tumor [see Contraindications ]. If the patient develops a substantial increase in blood pressure and a previously undiagnosed pheochromocytoma is suspected, 5 to 10 mg of phentolamine mesylate, administered intravenously, has been shown to be effective in lowering blood pressure.
Hypoglycemia in Patients with Insulinoma
In patients with insulinoma, administration of glucagon may produce an initial increase in blood glucose; however, BAQSIMI administration may directly or indirectly (through an initial rise in blood glucose) stimulate exaggerated insulin release from an insulinoma and cause hypoglycemia. BAQSIMI is contraindicated in patients with insulinoma [see Contraindications ]. If a patient develops symptoms of hypoglycemia after a dose of BAQSIMI, give glucose orally or intravenously.
Hypersensitivity and Allergic Reactions
Allergic reactions have been reported with glucagon, these include generalized rash, and in some cases anaphylactic shock with breathing difficulties and hypotension. BAQSIMI is contraindicated in patients with a prior hypersensitivity reaction [see Contraindications ].
Lack of Efficacy in Patients with Decreased Hepatic Glycogen
BAQSIMI is effective in treating hypoglycemia only if sufficient hepatic glycogen is present. Patients in states of starvation, with adrenal insufficiency or chronic hypoglycemia may not have adequate levels of hepatic glycogen for BAQSIMI administration to be effective. Patients with these conditions should be treated with glucose.
The following serious adverse reactions are described below and elsewhere in labeling:
- Hypersensitivity and Allergic Reactions [see Warnings and Precautions ].
Clinical Trial Data
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of BAQSIMI cannot be directly compared with rates in clinical trials of other drugs and may not reflect the rates observed in practice.
Adverse Reactions in Adult Patients
Two similarly designed comparator-controlled trials, Study 1 and Study 2, evaluated the safety of a single dose of BAQSIMI compared to a 1 mg dose of intra-muscular glucagon (IMG) in adult patients with diabetes [see Clinical Studies ].
Table 1 presents adverse reactions that occurred with BAQSIMI at an incidence of ≥2% in a pool of Study 1 and Study 2.
a Upper Respiratory Tract Irritation: rhinorrhea, nasal discomfort, nasal congestion, cough, and epistaxis. | |
| Adverse Reaction | BAQSIMI 3 mg (N=153) % |
| Nausea | 26.1 |
| Headache | 18.3 |
| Vomiting | 15.0 |
| Upper Respiratory Tract Irritationa | 12.4 |
Nasal and ocular symptoms with BAQSIMI were solicited through a patient questionnaire in Study 1 and 2 and these adverse reactions are presented in Table 2.
a Subjects were asked to report whether they have the symptom, as well as severity (mild, moderate, severe) at baseline, and after glucagon administration. | |
| Adverse Reactiona | BAQSIMI 3 mg (n=153) % |
| Any increase in symptom severitya | |
| Watery eyes | 58.8 |
| Nasal congestion | 42.5 |
| Nasal itching | 39.2 |
| Runny nose | 34.6 |
| Redness of eyes | 24.8 |
| Itchy eyes | 21.6 |
| Sneezing | 19.6 |
| Itching of throat | 12.4 |
| Itching of ears | 3.3 |
Adverse Reactions in Pediatric Patients Aged 4 Years and Above
A single dose of BAQSIMI was compared to weight-based doses of 0.5 mg or 1 mg of IMG in pediatric patients with type 1 diabetes in Study 3 [see Clinical Studies ].
Table 3 presents adverse reactions that occurred with BAQSIMI in pediatric patients at an incidence of ≥2% in Study 3.
a Upper Respiratory Tract Irritation: nasal discomfort, nasal congestion, sneezing. | |
| Adverse Reaction | BAQSIMI 3 mg (n=36) % |
| Vomiting | 30.6 |
| Headache | 25.0 |
| Nausea | 16.7 |
| Upper Respiratory Tract Irritationa | 16.7 |
Nasal and ocular symptoms with BAQSIMI were solicited through a patient questionnaire in pediatric patients in Study 3 and these adverse reactions are presented in Table 4.
a Subjects were asked to report whether they have the symptom, as well as severity (mild, moderate, severe) at baseline, and after glucagon administration. | |
| Adverse Reactiona | BAQSIMI 3 mg (n=36) % |
| Any increase in symptom severitya | |
| Watery eyes | 47.2 |
| Nasal congestion | 41.7 |
| Nasal itching | 27.8 |
| Runny nose | 25.0 |
| Sneezing | 19.4 |
| Itchy eyes | 16.7 |
| Redness of eyes | 13.9 |
| Itching of throat | 2.8 |
| Itching of ears | 2.8 |
Other Adverse Reactions in Adult and Pediatric Patients
Other observed adverse reactions with BAQSIMI-treated patients across clinical trials were, dysgeusia, pruritus, tachycardia, hypertension, and additional upper respiratory tract irritation events (nasal pruritus, throat irritation, and parosmia).
Immunogenicity
As with all therapeutic peptides, there is the potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence of antibodies to BAQSIMI with the incidences of antibodies to other products may be misleading.
In 3 clinical trials, 3/124 (2%) of BAQSIMI-treated patients had treatment-emergent anti-drug antibodies as detected by an affinity capture elution (ACE) ligand-binding immunogenicity assay. No neutralizing antibodies were detected.
Beta-blockers
Patients taking beta-blockers may have a transient increase in pulse and blood pressure when given BAQSIMI.
Indomethacin
In patients taking indomethacin, BAQSIMI may lose its ability to raise blood glucose or may even produce hypoglycemia.
Warfarin
BAQSIMI may increase the anticoagulant effect of warfarin.
BAQSIMI contains glucagon, an antihypoglycemic agent used to treat severe hypoglycemia. Glucagon is a single-chain polypeptide containing 29 amino acid residues and has a molecular weight of 3483, and is identical to human glucagon.
Its molecular formula is C153H225N43O49S, with the following molecular structure:
BAQSIMI is a preservative-free, white powder for intranasal administration in an intranasal device containing one dose of 3 mg glucagon. BAQSIMI contains glucagon as the active ingredient and betadex, and dodecylphosphocholine as the excipients.
Mechanism of Action
Glucagon increases blood glucose concentration by activating hepatic glucagon receptors, thereby stimulating glycogen breakdown and release of glucose from the liver. Hepatic stores of glycogen are necessary for glucagon to produce an antihypoglycemic effect.
Pharmacodynamics
After administration of BAQSIMI in adult patients with diabetes, the mean maximum glucose increase from baseline was 140 mg/dL .
In pediatric patients with type 1 diabetes (4 to <17 years), the mean maximum glucose increase from baseline was 138 mg/dL (4 to <8 years), 133 mg/dL (8 to <12 years), and 102 mg/dL (12 to <17 years) .
Sex and body weight had no clinically meaningful effects on the pharmacodynamics of BAQSIMI.
Common cold with nasal congestion tested with or without use of decongestant did not impact pharmacodynamics of BAQSIMI.
Figure 1 Mean glucose concentration over time after glucagon dose in adult Type 1 Diabetes patients with insulin-induced hypoglycemia.
Figure 2 Mean glucose concentration over time in pediatric Type 1 Diabetes patients administered BAQSIMI
Pharmacokinetics
Absorption
Glucagon absorption via the intranasal route, achieved mean peak plasma levels of 6130 pg/mL at around 15 minutes.
Distribution
The apparent volume of distribution was approximately 885 L.
Elimination
The median half-life was approximately 35 minutes.
Metabolism
Glucagon is known to be degraded in the liver, kidneys, and plasma.
Specific Populations
Pediatrics
In pediatric patients (4 to <17 years), glucagon via the intranasal route, achieved mean peak plasma levels between 15 and 20 minutes. The median half-life was 21 to 31 minutes.
Patients with Colds
Common cold with nasal congestion did not impact the pharmacokinetics of BAQSIMI.
Drug Interaction Studies
Common cold with use of decongestant did not impact the pharmacokinetics of BAQSIMI.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Long term studies in animals to evaluate carcinogenic potential have not been performed. Recombinant glucagon was positive in the bacterial Ames assay. It was determined that an increase in colony counts was related to technical difficulties in running this assay with peptides. Studies in rats have shown that glucagon does not cause impaired fertility.
Adult Patients
Study 1 (NCT03339453) was a randomized, multicenter, open-label, 2-period, crossover study in adult patients with type 1 diabetes. The efficacy of a single 3 mg dose of BAQSIMI was compared to a 1 mg dose of intra-muscular glucagon (IMG). Insulin was used to reduce blood glucose levels to <60 mg/dL. Seventy patients were enrolled, with a mean age of 41.7 years and a mean diabetes duration of 20.1 years. Twenty-seven (39%) were female.
The primary efficacy outcome measure was the proportion of patients achieving treatment success, which was defined as either an increase in blood glucose to ≥70 mg/dL or an increase of ≥20 mg/dL from glucose nadir within 30 minutes after receiving study glucagon, without receiving additional actions to increase the blood glucose level. Glucose nadir was defined as the minimum glucose measurement at the time of, or within 10 minutes, following glucagon administration.
The mean nadir blood glucose was 54.5 mg/dL for BAQSIMI and 55.8 mg/dL for IMG. BAQSIMI demonstrated non-inferiority to IMG in reversing insulin-induced hypoglycemia with 100% of BAQSIMI-treated patients and 100% of IMG-treated patients achieving treatment success. The mean time to treatment success was 11.6 and 9.9 minutes in the BAQSIMI and IMG 1 mg treatment groups, respectively.
a The Efficacy Analysis Population consisted of all patients who received both doses of the Study Drug with evaluable primary outcome. | ||
b Difference calculated as (percentage with success in BAQSIMI) – (percentage with success in IMG). | ||
c 2-sided 95% confidence interval (CI) of paired differences using a Wald-Min correction; non-inferiority margin = -10%. | ||
| Type 1 Diabetes (N=66)a | ||
| BAQSIMI 3 mg | IMG 1 mg | |
| Treatment Success – n (%) | 66 (100%) | 66 (100%) |
| Treatment Difference (2-sided 95% confidence limit)b, c | 0% (-2.9%, 2.9%) | |
| Glucose criterion met – n (%) | ||
| (i) ≥70 mg/dL (ii) Increase by ≥20 mg/dL from nadir Both (i) and (ii) | 66 (100%) 66 (100%) 66 (100%) | 66 (100%) 66 (100%) 66 (100%) |
Study 2 (NCT01994746) was a randomized, multicenter, open-label, 2-period, crossover study in adult patients with type 1 diabetes or type 2 diabetes. The efficacy of a single 3 mg dose of BAQSIMI was compared to a 1 mg dose of intra-muscular glucagon (IMG). Insulin was used to reduce blood glucose levels to the hypoglycemic range with a target blood glucose nadir of <50 mg/dL.
Study 2 enrolled 83 patients 18 to <65 years of age. The mean age of patients with type 1 diabetes (N=77) was 32.9 years and a mean diabetes duration of 18.1 years, and 45 (58%) patients were female. The mean age of patients with type 2 diabetes (N=6) was 47.8 years, with a mean diabetes duration of 18.8 years, and 4 (67%) patients were female.
The mean nadir blood glucose was 44.2 mg/dL for BAQSIMI and 47.2 mg/dL for IMG. BAQSIMI demonstrated non-inferiority to IMG in reversing insulin-induced hypoglycemia with 98.8% of BAQSIMI-treated patients and 100% of IMG-treated patients achieving treatment success within 30 minutes.
The mean time to treatment success was 15.9 and 12.1 minutes in the BAQSIMI and IMG 1 mg treatment groups, respectively.
a The Efficacy Analysis Population consisted of all patients who received both doses of the Study Drug with evaluable primary outcome. | ||
b Difference calculated as (percentage with success in BAQSIMI) – (percentage with success in IMG). | ||
c 2-sided 95% confidence interval (CI) of paired differences using a Wald-Min correction; non-inferiority margin = -10%. | ||
d Percentage based on number of patients. | ||
| Type 1 and Type 2 Diabetes (N=80)a | ||
| BAQSIMI 3 mg | IMG 1 mg | |
| Treatment Success – n (%) | 79 (98.8%) | 80 (100%) |
| Treatment Difference (2-sided 95% confidence limit)b,c | -1.3% (-4.6%, 2.2%) | |
| Glucose criterion met – n (%)d | ||
| (i) ≥70 mg/dL | 77 (96%) | 79 (99%) |
| (ii) Increase by ≥20 mg/dL from nadir | 79 (99%) | 80 (100%) |
| Both (i) and (ii) | 77 (96%) | 79 (99%) |
Pediatric Patients
Study 3 (NCT01997411) was a randomized, multicenter, clinical study that assessed BAQSIMI compared to intra-muscular glucagon (IMG) in pediatric patients aged 4 years and older with type 1 diabetes. Insulin was used to reduce blood glucose levels, and glucagon was administered after glucose reached <80 mg/dL. Efficacy was assessed based on percentage of patients with a glucose increase of ≥20 mg/dL from glucose nadir within 30 minutes following BAQSIMI administration.
Forty-eight patients were enrolled and received at least one dose of study drug. The mean age in the Young Children cohort (4 to <8 years) was 6.5 years. In the Children cohort (8 to <12 years), mean age was 11.1 years and in the Adolescents cohort (12 to <17 years) mean age was 14.6 years. In all age cohorts, the population was predominantly male and white.
Across all age groups, all (100%) patients in both treatment arms achieved an increase in glucose ≥20 mg/dL from glucose nadir within 20 minutes of glucagon administration. The mean time to reach a glucose increase of ≥20 mg/dL for BAQSIMI and IMG for all age groups is shown in Table 7.
| Increase from Nadir | Mean Time Post-Glucagon Administration (minutes) | |||||
|---|---|---|---|---|---|---|
| Young Children (4 to <8 years old) | Children (8 to <12 years old) | Adolescents (12 to <17 years old) | ||||
| IMGa N=6 | BAQSIMI 3 mg N=12 | IMGa N=6 | BAQSIMI 3 mg N=12 | IMGa N=12 | BAQSIMI 3 mg N=12 | |
a 0.5 mg or 1 mg of IMG (based upon body weight) | ||||||
| ≥20 mg/dL | 10.8 | 10.8 | 12.5 | 11.3 | 12.5 | 14.2 |
BAQSIMI is supplied as an intranasal device containing one 3 mg dose of glucagon as a preservative free, white powder.
- BAQSIMI One Pack™ carton contains 1 intranasal device (NDC 0002-6145-11)
- BAQSIMI Two Pack™ carton contains 2 intranasal devices (NDC 0002-6145-27)
- Store at temperatures up to 86°F (30°C) in the shrink wrapped tube provided.
- Keep BAQSIMI in the shrink wrapped tube until ready to use. If the tube has been opened, BAQSIMI may have been exposed to moisture and may not work as expected.
- Discard BAQSIMI and tube after use.
INSTRUCTIONS FOR USE
BAQSIMI™
(glucagon) nasal powder
3 mg
Read the Instructions for Use for BAQSIMI before using it. BAQSIMI is used to treat very low blood sugar (severe hypoglycemia) that may cause you to need help from others. You should make sure you show your caregivers, family and friends where you keep BAQSIMI and explain how to use it by sharing these instructions. They need to know how to use BAQSIMI before an emergency happens.
| Tube and Device Parts |
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Important Information to Know
- Do not remove the Shrink Wrap or open the Tube until you are ready to use it.
- If the Tube has been opened, BAQSIMI could be exposed to moisture. This could cause BAQSIMI not to work as expected.
- Do not push the plunger or test BAQSIMI before you are ready to use it.
- BAQSIMI contains 1 dose of glucagon nasal powder and cannot be reused.
- BAQSIMI is for nasal (nose) use only.
- BAQSIMI will work even if you have a cold or are taking cold medicine.
Preparing the Dose
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Giving the Dose
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After giving BAQSIMI
- Call for emergency medical help right away.
- If the person is unconscious turn the person on their side.
- Throw away the used Device and Tube.
- Encourage the person to eat as soon as possible. When they are able to safely swallow, give the person a fast acting source of sugar, such as juice. Then encourage the person to eat a snack, such as crackers with cheese or peanut butter.
- If the person does not respond after 15 minutes, another dose may be given, if available.
Storage and Handling
- Do not remove the Shrink Wrap or open the Tube until you are ready to use it.
- Store BAQSIMI in the shrink wrapped Tube at temperatures up to 86º F (30ºC ).
- Replace BAQSIMI before the expiration date printed on the Tube or carton.
Other Information
- Caution: Replace the used BAQSIMI right away so you will have a new BAQSIMI in case you need it.
- Keep BAQSIMI and all medicines out of the reach of children.
For Questions or More Information about BAQSIMI
- Call your healthcare provider
- Call Lilly at 1-800-Lilly-Rx (1-800-545-5979)
- Visit www.baqsimi.com
BAQSIMI is a trademark of Eli Lilly and Company.
Marketed by: Lilly USA, LLC
Indianapolis, IN 46285, USA
Copyright © 2019, Eli Lilly and Company. All rights reserved.
| BAQSIMI Device meets all applicable requirements defined in ISO 20072 |
This Instructions for Use has been approved by the U.S. Food and Drug Adminstration
Issued: July 2019
BAQ-0001-IFU-20190724
Mechanism of Action
Glucagon increases blood glucose concentration by activating hepatic glucagon receptors, thereby stimulating glycogen breakdown and release of glucose from the liver. Hepatic stores of glycogen are necessary for glucagon to produce an antihypoglycemic effect.
Baqsimi Prior Authorization Resources
Most recent state uniform prior authorization forms
Financial Assistance Programs
- Program Expires 12/31/2025
- $1800 Annual Cap