How to treat a patient with hypoglycemia (low blood sugar) who is on insulin or oral hypoglycemic medications like metformin?

Treatment of Hypoglycemia in Patients on Insulin or Oral Hypoglycemic Medications

Immediate treatment of hypoglycemia should begin with 15-20g of fast-acting oral carbohydrates, followed by blood glucose monitoring every 15 minutes until normalization (>70 mg/dL). For patients unable to take oral carbohydrates, glucagon administration is indicated.

Immediate Management of Hypoglycemia

For Conscious Patients (Mild to Moderate Hypoglycemia)

1. Administer 15-20g of fast-acting carbohydrates 1:

   • 3-4 glucose tablets or glucose gel
   • 4 oz (120 mL) of fruit juice or regular soda
   • 1 tablespoon of honey or sugar dissolved in water
   • Avoid high-fat foods as they delay glucose absorption

2. Recheck blood glucose after 15 minutes 1

   • If still <70 mg/dL, repeat carbohydrate treatment
   • Continue this cycle until blood glucose normalizes (>70 mg/dL)

3. Once blood glucose normalizes, provide a meal or snack if the next meal is more than 1 hour away to prevent recurrence 1

For Unconscious Patients or Severe Hypoglycemia

1. Administer glucagon 1:

   • Intranasal glucagon (preferred due to ease of administration) 2
   • Ready-to-inject glucagon preparations for subcutaneous injection
   • Traditional glucagon injection (requires reconstitution)

2. Position patient on their side to prevent aspiration

3. Do not attempt to give oral carbohydrates to an unconscious patient

4. Call emergency services if no improvement after glucagon administration

Prevention of Hypoglycemia

Medication Adjustments

1. Insulin users:

   • Ensure proper timing of insulin in relation to meals
   • Consider reducing insulin doses for patients with recurrent hypoglycemia
   • Avoid sole use of sliding scale insulin regimens 1

2. Sulfonylurea users:

   • Take medication 30 minutes before meals 3
   • Consider discontinuing sulfonylureas in those with documented hypoglycemia 1
   • Consider switching to medications with lower hypoglycemia risk

3. Metformin users:

   • Take with or 15 minutes after meals to minimize side effects 3
   • Be aware that hypoglycemia can occur when metformin is combined with sulfonylureas or insulin 4, 5
   • Consider extended-release formulations for patients experiencing hypoglycemia with immediate-release metformin 6

Risk Assessment and Monitoring

1. Identify high-risk patients 1:

   • Elderly patients (≥65 years)
   • Previous severe hypoglycemia
   • Long duration of diabetes
   • Hypoglycemia unawareness
   • Chronic kidney disease
   • Liver disease
   • Frailty

2. Implement appropriate monitoring:

   • Consider continuous glucose monitoring for insulin users and high-risk patients 1
   • Regular self-monitoring of blood glucose, especially before driving and during periods of increased risk

Patient Education

1. Teach patients to recognize hypoglycemia symptoms:

   • Early symptoms: shakiness, sweating, hunger, anxiety, irritability
   • Neuroglycopenic symptoms: confusion, difficulty concentrating, weakness
   • Severe symptoms: seizures, loss of consciousness

2. Ensure patients have hypoglycemia treatment readily available:

   • Glucose tablets or gel
   • Prescribe glucagon for all insulin users and consider for sulfonylurea users 1
   • Train family members/caregivers on glucagon administration

3. Advise on preventive measures:

   • Consistent meal timing
   • Carbohydrate counting for insulin users
   • Medication timing in relation to meals
   • Adjustments for exercise or alcohol consumption

Special Considerations

1. Exercise: Advise checking glucose before, during, and after exercise; consider carbohydrate supplementation or insulin dose reduction

2. Alcohol consumption: Warn patients about increased hypoglycemia risk with alcohol, especially when combined with insulin or sulfonylureas 4

3. Medication interactions: Be aware that certain medications can potentiate hypoglycemia risk (e.g., beta-blockers can mask symptoms)

4. Institutional settings: Ensure staff are trained in hypoglycemia recognition and treatment, with protocols for prompt intervention 1

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