What is the management of hypoglycemia?

Management of Hypoglycemia

The management of hypoglycemia requires prompt recognition and treatment with 15-20g of fast-acting carbohydrates for mild to moderate hypoglycemia (blood glucose <70 mg/dL), or glucagon injection for severe hypoglycemia requiring assistance from another person. 1

Classification and Treatment Algorithm

The American Diabetes Association classifies hypoglycemia into three levels:

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 requiring assistance	Glucagon injection

Step-by-Step Treatment Protocol

1. For Level 1 and 2 Hypoglycemia (Patient Conscious):

   • Administer 15-20g of fast-acting carbohydrates 2, 1
   • Options include:
     • 4 glucose tablets (4g each)
     • 4-6 oz fruit juice or regular soda
     • 1 tablespoon honey or syrup
   • Recheck blood glucose after 15 minutes
   • If blood glucose remains <70 mg/dL, repeat treatment
   • Once blood glucose normalizes, provide a meal or snack with protein and complex carbohydrates to prevent recurrence 1

2. For Level 3 Hypoglycemia (Severe - Patient Unconscious or Unable to Swallow):

   • Administer glucagon 3:
     • Adults and children >25kg: 1mg subcutaneously or intramuscularly
     • Children <25kg: 0.5mg subcutaneously or intramuscularly
   • Inject into upper arm, thigh, or buttocks
   • Call for emergency assistance immediately after administration
   • If no response after 15 minutes, administer a second dose while waiting for emergency assistance 3
   • After the patient regains consciousness, provide oral carbohydrates to restore liver glycogen 3

Hospital Management

For hospitalized patients, a standardized hypoglycemia protocol should be implemented 2:

• Adopt a hospital-wide, nurse-initiated hypoglycemia treatment protocol for blood glucose <70 mg/dL
• Document all hypoglycemic episodes in the medical record
• Review treatment regimens when blood glucose <70 mg/dL is documented to prevent further episodes 2
• Monitor glucose levels every 15-30 minutes initially, then hourly after treatment 1

Prevention Strategies

1. Medication Management:

   • Match mealtime insulin to carbohydrate intake
   • Consider reducing insulin doses if physical activity is planned
   • Use modern insulin formulations with lower hypoglycemia risk 1
   • Avoid first-generation sulfonylureas, especially in patients with renal impairment 1

2. Lifestyle Modifications:

   • Maintain regular meal patterns and never skip meals
   • Carry quick-acting carbohydrates at all times
   • Limit alcohol consumption as it inhibits glucose release from the liver 1
   • Increase frequency of blood glucose monitoring during illness, exercise, or changes in routine 1

3. For Recurrent Hypoglycemia:

   • Temporarily raise glycemic targets to strictly avoid hypoglycemia for several weeks to partially reverse hypoglycemia unawareness 2
   • Prescribe glucagon for all individuals at risk of level 2 or 3 hypoglycemia 1
   • Consider continuous glucose monitoring for patients with frequent hypoglycemia 1
   • Conduct ongoing assessment of cognitive function with increased vigilance for hypoglycemia in patients with low or declining cognition 2

Patient Education

Education is critical for effective hypoglycemia management 1:

• Teach patients and caregivers to recognize hypoglycemia symptoms (shakiness, irritability, confusion, tachycardia, hunger) 2
• Instruct on proper use of glucagon and ensure caregivers know where it is stored 3
• Recommend wearing a medical alert bracelet or necklace 1
• Educate about situations that increase hypoglycemia risk (fasting, delayed meals, exercise, sleep) 2

Special Considerations

• For patients with sulfonylurea-induced hypoglycemia, extended monitoring is required due to prolonged action 1
• After apparent clinical recovery, continued observation and additional carbohydrate intake may be necessary to prevent recurrence 1
• Hypoglycemia unawareness requires a period of scrupulous avoidance of hypoglycemia to restore awareness 4
• High-fat foods should not be used to treat acute hypoglycemia as they slow glucose absorption 1

Hypoglycemia remains a major barrier to achieving optimal glycemic control in diabetes management 5, 6. Effective prevention and treatment strategies are essential to reduce the associated morbidity and mortality while allowing patients to maintain target glucose levels.