We estimated global glucagon sales in the years2014-2021 using the IQVIA-Multinational Integrated Data Analysis System (IQVIA-MIDAS®) database . IQVIA-MIDAS is a commercial database containing data from pharmacy retail sales throughout the supply chains, including overall glucagon volume sold to retailers and hospital pharmacies by wholesalers. The proportion of wholesalers contributing data to IQVIA-MIDAS varies between represented countries and IQVIA adjusts the reported data based on the market share of participating wholesalers, to provide estimates of total sales in the sectors represented in each country. This dataset contains annual pharmaceutical sales data for 75 countries/regions. Annual sales of glucagon (including information on component glucagon, formulation, trade name and manufacturer) are recorded for each country. Glucagon sales were expressed in standard units (SU), with 1 SU defined by IQVIA as one emergency kit, nasal set, or injectable easy-to-use glucagon. The IQVIA-MIDAS® analytics platform is validated annually by calculation of a ‘global precision index’ (94.3% in 2017) . Data of distribution and sales of glucagon, [old formulations (Glucagon, Glucagen) and new ready-to-use glucagons (Baqsimi, Gvoke, Zegalogue)] were requested to IQVIA for Algeria, Argentina, Australia, Austria, Bangladesh, Belarus, Belgium, Bosnia, Brazil, Bulgaria, Central America, Canada, Chile, China, Colombia, Croatia, Czech Republic, Dominican Republic, Ecuador, Egypt, Estonia, Finland, French West Africa, France, Germany, Greece, Hong Kong, Hungary, India, Indonesia, Ireland, Italy, Japan, Jordan, Kazakhstan, Korea, Kuwait, Latvia, Lebanon, Lithuania, Luxembourg, Malaysia, Mexico, Morocco, Netherlands, New Zealand, Norway, Pakistan, Peru, Philippines, Poland, Portugal, Puerto Rico, Romania, Russian Federation, South Africa, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, Spain, Sri Lanka, Sweden, Switzerland, Taiwan, Thailand, Tunisia, Turkey, UAE, UK, Uruguay, US, Venezuela, Vietnam. Data for European countries where Baqsimi was eventually available (Belgium, Bulgaria, Slovakia, France, Germany, Greece, Hungary, Italy, Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Spain) were grouped under the label Europe, at difference from UK, Turkey, and Ireland, where Baqsimi did not become available.
New ready-to-use glucagons were available in four specified regions (US, Canada, Europe, and Japan, Group A), their data were analyzed by country and together, as well as data for countries where the new formulations were not available (Group B). Data collected referred only to retail sales; since the use of glucagon in hospital settings is not only limited to management of hypoglycemia, these data were deliberately ignored. Data were always expressed as referred to persons with type 1 diabetes.
The period analyzed included 2014–2021 to compare sales before and after availability of Baqsimi, Gvoke, Zegalogue. This was intended to understand the spontaneous pattern of traditional glucagon kits for a long enough period. Data on number of persons with type 1 diabetes in different countries were derived from the 2021 edition of the IDF diabetes atlas ; however, these data should be interpreted with caution, since methods of calculation varied from year to year (prevalence × 1000 in 2013, × 100.000 for 2015 and 2017, absolute numbers for 2019 and 2021) . A very recent publication reported significantly higher estimates for the prevalence of type 1 diabetes in different countries in 2021 . This study was considered for completeness, and correlation between sales and persons with type 1 diabetes is presented in the Additional file 1. This study followed the guidelines for cohort studies, described in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline .