What is the management of hypoglycemia?

Management of Hypoglycemia

The management of hypoglycemia requires immediate treatment with 15-20g of oral glucose for mild to moderate cases (blood glucose <70 mg/dL), while severe hypoglycemia necessitates glucagon injection or IV glucose administration when the patient requires external assistance. 1

Classification and Diagnosis

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 status requiring assistance	Glucagon injection

Acute Management Protocol

For Conscious Patients (Level 1 and 2)

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

   • 3-4 glucose tablets
   • 4-6 oz of fruit juice or regular soda
   • 1 tablespoon of honey or sugar
   • Avoid high-fat foods as they delay glucose absorption 1

2. Recheck blood glucose after 15 minutes

3. Repeat treatment if blood glucose remains <70 mg/dL

4. Once blood glucose normalizes, provide a meal or snack containing protein and complex carbohydrates to prevent recurrence

For Unconscious Patients or Those Unable to Swallow (Level 3)

1. First-line treatment: Administer intravenous glucose (D10W 50mL aliquots, up to 25g total) 1
2. If IV access is unavailable, administer glucagon:
   • Adults and children >25kg: 1mg intramuscularly or subcutaneously
   • Children <25kg: 0.5mg
3. Target blood glucose level of 100-140 mg/dL to avoid overcorrection 1
4. Every patient on insulin should be prescribed glucagon for emergency use 2, 1
5. Consider prescribing glucagon to patients taking sulfonylureas who meet at-risk criteria 2

Prevention Strategies

Medication Adjustments

1. Delay use of medications associated with hypoglycemia (insulin, sulfonylureas) until other options have been exhausted 2
2. For patients already using insulin or sulfonylureas:
   • Consider switching to a non-hypoglycemic regimen
   • De-intensify current regimen
   • Consider stopping sulfonylureas in those with documented hypoglycemia 2

Monitoring

1. Recommend continuous glucose monitoring (CGM) over self-monitoring of blood glucose (SMBG) in patients using insulin 2
2. Consider CGM for sulfonylurea users 2
3. Ask patients about hypoglycemia incidents at every visit 2
4. Document all episodes of hypoglycemia in the medical record and track for quality improvement 2

Risk Assessment

Identify patients at higher risk for hypoglycemia:

• Use of insulin or sulfonylureas
• Age ≥65 years
• Previous severe hypoglycemia
• Long duration of diabetes
• Hypoglycemia unawareness
• Chronic kidney disease
• Liver disease
• Frailty and/or high comorbidity burden 2

Hospital Management

1. Adopt and implement a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol for blood glucose <70 mg/dL 2
2. Review treatment plan any time a blood glucose value of <70 mg/dL occurs 2
3. For hospitalized patients with recurrent hypoglycemia:
   • Adjust basal insulin doses, particularly for overnight hypoglycemia
   • Evaluate timing of insulin administration relative to meals
   • Review all medications for potential interactions 2

Patient Education and Follow-up

1. Teach patients to recognize hypoglycemic symptoms (shakiness, irritability, confusion, tachycardia, hunger) 1
2. Instruct patients to always carry fast-acting carbohydrates 1
3. Educate on lifestyle factors:
   • Consistent meal timing
   • Appropriate carbohydrate counting
   • Insulin adjustment for planned exercise
   • Limiting alcohol consumption
   • Stress management 1
4. Schedule follow-up within 1-2 weeks to review blood glucose logs and adjust medication regimen 1
5. For recurrent hypoglycemia or hypoglycemia unawareness, implement a 2-3 week period of scrupulous avoidance of hypoglycemia 1

Special Considerations

Critical Illness

• Maintain blood glucose levels <180 mg/dL while avoiding hypoglycemia 1
• Focus on preventing hypoglycemia rather than achieving tight control

Elderly Patients

• Use more conservative glucose targets
• Simplify regimens to reduce hypoglycemia risk 1

Comorbidities

• Patients with renal or hepatic impairment require more careful monitoring and dose adjustments 3
• Consider rare causes of hypoglycemia in patients with unexplained episodes (cortisol insufficiency, insulinoma, genetic causes) 4

Clinical Implications

Hypoglycemia is associated with significant morbidity and mortality:

• Moderate hypoglycemia (41-70 mg/dL): 28.5% mortality rate
• Severe hypoglycemia (≤40 mg/dL): 35.4% mortality rate 1
• Recurrent hypoglycemia: 3.4-fold increased risk of death within 5 years 1
• Long-term complications include cerebrovascular disease, myocardial infarction, neurocognitive dysfunction, and retinal cell death 5

By implementing these management strategies, healthcare providers can effectively treat acute hypoglycemia while minimizing the risk of recurrence and associated complications.