What is the workup and treatment for a patient with diabetes presenting with hypoglycemia (low blood sugar)?

From the Guidelines

For a diabetic patient presenting with low blood sugar (hypoglycemia), immediate treatment involves administering 15-20 grams of fast-acting carbohydrates, such as glucose, to rapidly correct the blood glucose level, as recommended by the most recent guidelines 1. The treatment approach should be tailored to the severity of hypoglycemia, with level 1 hypoglycemia (blood glucose <70 mg/dL but ≥54 mg/dL) being managed with glucose administration, and level 2 hypoglycemia (blood glucose <54 mg/dL) requiring immediate action to resolve the hypoglycemic event, which may include glucagon administration if the patient is unconscious or unable to take glucose orally 1. Some key points to consider in the management of hypoglycemia include:

• Administering 15-20 grams of glucose, and rechecking blood glucose after 15 minutes to determine if additional treatment is needed 1
• Providing a small snack containing protein and complex carbohydrates once blood glucose returns to normal, to prevent recurrence of hypoglycemia 1
• Prescribing glucagon for individuals at increased risk of level 2 or 3 hypoglycemia, and ensuring that caregivers or family members know how to administer it 1
• Reevaluating and adjusting the treatment plan for patients with recurrent hypoglycemia, or those with hypoglycemia unawareness or level 3 hypoglycemia, which may involve adjusting diabetes medications or raising glycemic targets to strictly avoid hypoglycemia for a period of time 1 The workup for a patient presenting with hypoglycemia should include a detailed history, laboratory tests such as comprehensive metabolic panel, HbA1c, and thyroid function tests, and consideration of contributing factors such as renal impairment or adrenal insufficiency 1. Patient education about hypoglycemia recognition, prevention, and management is essential, and should be provided to all patients with diabetes, particularly those at increased risk of hypoglycemia 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

1. 1 Important Administration Instructions for Using the Glucagon Emergency Kit for Low Blood Sugar to Treat Severe Hypoglycemia Glucagon for Injection is for subcutaneous, intramuscular, or intravenous injection. Administer intravenously ONLY under medical supervision. Instruct patients and their caregivers on the signs and symptoms of severe hypoglycemia Because severe hypoglycemia requires the help of others to recover, instruct the patient to inform those around them about Glucagon for Injection and its Instructions for Use. Administer Glucagon for Injection 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 Glucagon for Injection Emphasize the following instructions to the patient or caregiver: Using the supplied prefilled syringe, carefully insert the needle through the rubber stopper of the vial containing Glucagon for Injection powder and inject all the liquid from the syringe into the vial. Shake the vial gently until the powder is completely dissolved and no particles remain in the fluid The reconstituted solution should be clear and colorless. Inspect visually for particulate matter and discoloration. If the resulting solution is cloudy or contains particulate matter do not use. The reconstituted solution is 1 mg per mL glucagon. Immediately after reconstitution, inject the solution subcutaneously or intramuscularly in the upper arm, thigh, or buttocks In addition, healthcare providers may administer intravenously. Call for emergency assistance immediately after administering the dose. When the patient has responded to the treatment and is able to swallow, give oral carbohydrates to restore the liver glycogen and prevent recurrence of hypoglycemia. Discard any unused portion.

The treatment for a diabetes patient with low blood sugar involves administering Glucagon for Injection as soon as possible when severe hypoglycemia is recognized. The recommended dosage is:

• 1 mg (1 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously for adults and pediatric patients weighing more than 25 kg or for pediatric patients with unknown weight 6 years and older.
• 0.5 mg (0.5 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously for pediatric patients weighing less than 25 kg or for pediatric patients with unknown weight less than 6 years of age. If there has been no response after 15 minutes, an additional dose of Glucagon for Injection may be administered using a new kit while waiting for emergency assistance. After the patient has responded to the treatment and is able to swallow, give oral carbohydrates to restore the liver glycogen and prevent recurrence of hypoglycemia 2.

From the Research

Workup for Diabetes with Low Blood Sugar

• The workup for a diabetes patient with low blood sugar involves assessing the patient's symptoms, medical history, and current medications 3
• It is essential to identify the cause of low blood sugar, which can be due to various factors such as insulin or oral hypoglycemic agents, to provide appropriate treatment 4
• The patient's blood glucose levels, electrolyte levels, and kidney function should be monitored to determine the severity of the condition 5

Treatment for Low Blood Sugar in Diabetes Patients

• Treatment for low blood sugar in diabetes patients typically involves administering glucose or glucagon to raise blood glucose levels 3
• In severe cases, hospitalization may be necessary to monitor the patient's condition and provide supportive care 6
• Education and regular review are crucial for patients with diabetes and their caregivers to recognize the symptoms of low blood sugar and take appropriate action 3

Management of Diabetes to Prevent Low Blood Sugar

• The management of diabetes involves a combination of lifestyle modifications, such as diet and exercise, and medications to control blood glucose levels 4
• Oral hypoglycemic agents, such as metformin, sulfonylureas, and insulin secretagogues, can be used to lower blood glucose levels, but they can also increase the risk of low blood sugar 4, 6
• Insulin therapy can be effective in reducing hyperglycemia, but it is associated with weight gain and an increased risk of hypoglycemia 5
• Newer classes of antidiabetes agents, such as GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors, can improve glycemic control with a lower risk of hypoglycemia and weight gain 5, 7

Insulin Titration Strategies for Glycemic Control

• Adjusting basal insulin doses is essential for lowering blood glucose while minimizing the risk of hypoglycemia 7
• Self-titration at least twice a week with healthcare provider support can lead to superior HbA1c reduction in comparison with other strategies, without increasing the risk of severe hypoglycemia 7
• The choice of insulin titration strategy should be individualized based on the patient's needs and medical history 7