What is the proper management of hypoglycemia (low blood sugar)?

Management of Hypoglycemia

The recommended treatment for hypoglycemia is 15-20g of oral glucose or fast-acting carbohydrates, followed by reassessment after 15 minutes and repeated treatment if hypoglycemia persists. 1

Classification and Treatment Algorithm

Hypoglycemia is classified into three levels according to the American Diabetes Association:

Level	Blood Glucose	Description	Treatment
1	<70 mg/dL and ≥54 mg/dL	Mild hypoglycemia	15-20g oral glucose
2	<54 mg/dL	Moderate hypoglycemia	15-20g oral glucose
3	Any level	Severe event with altered mental/physical state requiring assistance	Glucagon injection

Acute Management of Hypoglycemia

For Conscious Patients Who Can Swallow

1. Administer 15-20g of glucose or fast-acting carbohydrates

   • Glucose tablets are preferred (most effective) 1
   • Alternatives include fruit juice, regular soda, or hard candy 2
   • When blood glucose is 50-60 mg/dL, 15g of glucose can raise levels by approximately 50 mg/dL 2

2. Wait 15 minutes and recheck blood glucose 1

3. If hypoglycemia persists, repeat treatment with 15g carbohydrate 2, 1

4. Once blood glucose normalizes, consume a small balanced meal or snack with protein and complex carbohydrates to prevent recurrence 1

For Severe Hypoglycemia (Unconscious or Unable to Swallow)

1. Administer glucagon:

   • Adults and children >25kg: 1mg subcutaneously or intramuscularly 3
   • Children <25kg: 0.5mg subcutaneously or intramuscularly 3
   • Injection sites: upper arm, thigh, or buttocks 3

2. Call for emergency assistance immediately after administration 3

3. When patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence 3

Special Considerations

Medication-Specific Considerations

• For patients on α-glucosidase inhibitors: Use glucose tablets specifically (not other carbohydrates) as these drugs prevent digestion of polysaccharides 2, 1

• For patients on insulin: Monitor for hypoglycemia especially during physical activity; always carry fast-acting carbohydrates 2, 4

• For sulfonylurea-induced hypoglycemia: Extended monitoring is required due to longer duration of action 1

High-Risk Situations

• Physical activity: May cause hypoglycemia depending on timing; consider reducing mealtime insulin if activity is within 1-2 hours of injection 2

• Patients with hypoglycemia unawareness: May need temporarily raised glycemic targets to restore awareness 1

• Nocturnal hypoglycemia: Consider using modern basal insulins with lower rates of nocturnal hypoglycemia 5

Prevention Strategies

1. Regular meal patterns:

   • Do not skip meals 2
   • Consume moderate amounts of carbohydrates at each meal 2

2. Medication management:

   • Match insulin doses to carbohydrate intake 2
   • Consider modern insulin formulations with lower hypoglycemia risk 5

3. Monitoring:

   • Consider continuous glucose monitoring for patients with recurrent hypoglycemia 1
   • Monitor more frequently during illness, exercise, or changes in routine

4. Education:

   • Ensure patients, family members, and caregivers know how to recognize and treat hypoglycemia 1
   • Prescribe glucagon for all individuals at risk of level 2 or 3 hypoglycemia 1

Common Pitfalls to Avoid

1. Using high-fat foods to treat acute hypoglycemia - these slow glucose absorption 1

2. Overtreatment - can lead to rebound hyperglycemia

3. Inadequate follow-up meal - after initial treatment, a balanced snack is needed to prevent recurrence 2, 1

4. Failure to identify the cause - addressing the underlying cause is essential to prevent future episodes 1

5. Ignoring patterns of hypoglycemia - recurring episodes at similar times may indicate need for medication adjustment

By following this structured approach to hypoglycemia management, clinicians can effectively treat acute episodes and implement strategies to reduce the risk of recurrence, ultimately improving patient outcomes and quality of life.