More than 10% of the United States population has diabetes, characterized by hyperglycemia. Insulin and other agents used to treat diabetes predispose people to hypoglycemia, which can be life threatening. Glucagon is an emergency medication that can save lives by quickly raising glucose in people who are unconscious or unable to consume glucose due to severe hypoglycemia. Although glucagon has been commercially available since 1960, earlier formulations required reconstitution of a dry powder with diluent immediately prior to injection, due to lack of long-term stability once reconstituted. Glucagon has been underutilized due to the lack of confidence or ability to administer in emergency situations. More recently, new formulations including a nasal powder glucagon and liquid-stable glucagon have become available. This article discusses the evidence surrounding new glucagon formulations compared with the original glucagon emergency kit including ease of use, efficacy, and safety with a focus on important patient counseling points and relevant clinical information on hypoglycemia.

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I would like to thank the authors of the recent article "Safety and Efficacy of High-dose Unfractionated Heparin for Prevention of Venous Thromboembolism in Overweight and Obese Patients" that has contributed more to the body of literature in venous thromboembolism (VTE) prophylaxis for patients with obesity. 1 This study provided evidence against the use of high-dose unfractionated heparin (UFH) thromboprophylaxis for obese patients. These results differ from those of a previous study that found a lower incidence of VTE for patients on high-dose UFH. 2 This conflicting evidence may leave clinicians unsure of how to provide appropriate thromboprophylaxis for obese patients. The conflicting findings of these two studies could be related to differences in study designs and analysis.One of these differences is that patients were compared by body mass index (BMI) every 5 kg/m 2 by the more recent study, whereas the other one compared BMI lower than 40 kg/m 2 to BMI higher than 40 kg/m 2 . Because the latter authors only found a lower incidence of VTE on high-dose thromboprophylaxis for those with a BMI higher than 40 kg/m 2 , would the authors of the more recent study have found a benefit if they had compared all those with a BMI higher than 40 kg/m 2 with all those with a BMI lower than 40 kg/m 2 ?The older trial included enoxaparin 40 mg subcutaneously (SC) twice/day as a high-dose option.There are data that suggest enoxaparin is superior to UFH, with one meta-analysis of randomized controlled trials finding a 37% risk reduction compared with UFH in total VTE for medical patients, with a nonsignificant difference in bleeding. 3 Another study found no significant differences between heparin 7500 units SC every 8 hours compared with 5000 units SC every 8 hours, suggesting that high-dose UFH may not benefit obese patients. 4 However, that study had limitations, such as differences in baseline factors that increased bleeding and VTE risk in the highdose group. Therefore, the inclusion of enoxaparin in the older study as compared with only UFH by the more recent one may have driven the differences in observed outcomes. By including high-dose enoxaparin as a high-dose thromboprophylaxis option and by analyzing the effect of enoxaparin separately from UFH, a benefit may have been found in the more recent study.Because studies like these help increase our understanding in this area, they also lead to further questions. More specific evidence is needed to guide the approach to VTE prophylaxis properly in obese patients. Future studies to decrease the incidence of VTE while minimizing the risk of bleeding should examine the use of high-dose VTE prophylaxis with enoxaparin 40 mg SC twice/day for those with a BMI higher than 40 kg/m 2 . References 1. Joy M, Tharp E, Hartman H, Schepcoff S, et al. Safety and efficacy of high-dose unfractionated heparin for prevention of venous thromboembolism in overweight and obese patients. Pharmacotherapy 2016;36(7):740-8.