At what rate should dextrose (glucose) be administered for acute hypoglycemia?

Dextrose Administration for Acute Hypoglycemia

For acute hypoglycemia, administer 10-25 grams of dextrose via slow intravenous push, with 10% dextrose (D10) in 5g aliquots being the preferred concentration due to similar efficacy with fewer side effects compared to 50% dextrose (D50). 1, 2

Initial Treatment Protocol

Adult Patients

• First-line treatment:

  • For blood glucose <60 mg/dL: Administer 10% dextrose in 5g (50mL) aliquots via slow IV push 3, 1
  • Maximum rate: 0.5 g/kg/hour to avoid glycosuria 2
  • Target blood glucose: >70 mg/dL (>100 mg/dL in neurologic injury patients) 1

• Alternative if D10 unavailable:

  • 25 mL of 50% dextrose (D50) via slow IV push 3, 2
  • Consider diluting D50 to D10 or D25 to reduce vein irritation 1

Monitoring and Follow-up

• Check blood glucose 10-20 minutes after initial treatment 3
• Recheck at 60 minutes as additional treatment may be necessary 3
• Monitor for recurrent hypoglycemia, especially in patients on long-acting insulin or oral hypoglycemic agents 1

Evidence-Based Advantages of D10 vs D50

D10 offers several advantages over D50:

1. Similar efficacy: Multiple studies show equivalent symptom resolution rates (95.9% for D10 vs 88.8% for D50) 4
2. Lower post-treatment hyperglycemia: Median post-treatment blood glucose levels are significantly lower with D10 (6.2 mmol/L vs 9.4 mmol/L with D50) 5
3. Fewer adverse events: No adverse events reported with D10 compared to 13/310 with D50 in comparative studies 4
4. Lower total dose administered: Median total dose is typically lower with D10 (10g vs 25g with D50) 5, 6

Special Considerations

• Oral glucose options: If patient is conscious and able to swallow, oral glucose (15-20g) is effective and preferred 3, 1
• Neurologic injury patients: Maintain higher glucose targets (>100 mg/dL) 1
• IV access issues: Consider glucagon 1mg IM if IV access is difficult, though response is slower 1
• Fluid management: Use isotonic solutions like 0.9% saline rather than hypotonic solutions for maintenance fluids in stroke patients with hypoglycemia 3
• Dosing caution: Avoid rapid administration of concentrated dextrose solutions due to risk of cardiac arrest and hyperkalemia 1

Clinical Pearls

• Pure glucose is more effective than equivalent carbohydrate amounts from juice or milk for treating hypoglycemia 3
• Patients with poorly controlled diabetes may experience symptoms at higher blood glucose thresholds 3
• D10 may require slightly longer time to achieve symptom resolution (8 minutes vs 4 minutes with D50) but with fewer adverse effects 4
• For patients with pretreatment blood glucose <110 mg/dL or without diabetes, 50g of dextrose may be more effective at preventing subsequent hypoglycemia 7

The evidence strongly supports using D10 in 5g aliquots as the preferred treatment for acute hypoglycemia, offering an optimal balance of efficacy and safety while minimizing the risk of post-treatment hyperglycemia.