What should be done for nocturnal hypoglycemia (low blood sugar at 0400)?

Management of Nocturnal Hypoglycemia (Low Blood Sugar at 0400)

For nocturnal hypoglycemia at 0400, immediately administer 15-20g of fast-acting carbohydrates, recheck blood glucose after 15 minutes, and repeat treatment if necessary until blood glucose is above 70 mg/dL. 1

Immediate Treatment Protocol

For Conscious Patients:

1. Administer 15-20g of fast-acting carbohydrates 1, 2:

   • Glucose tablets (preferred option)
   • Any form of carbohydrate containing glucose
   • Avoid high-fat foods as they slow glucose absorption

2. Recheck blood glucose after 15 minutes 1

3. If blood glucose remains <70 mg/dL, repeat treatment with another 15-20g of carbohydrates 1

4. Once blood glucose is >70 mg/dL, consider a small protein/carbohydrate snack if the next meal is more than 1 hour away to prevent recurrence 1

For Unconscious Patients or Those Unable to Swallow:

• Administer glucagon 1, 2:
  • Adults: 1mg subcutaneously or intramuscularly
  • Children: 30 mcg/kg subcutaneously (maximum 1mg)
  • Lower dose of 10 mcg/kg may cause less nausea while still being effective 2
• Activate emergency medical services 1

Follow-Up Management

After treating the acute episode:

1. Monitor blood glucose frequently for the next several hours as hypoglycemia may recur 1

2. Evaluate the cause of nocturnal hypoglycemia:

   • Review insulin dosing (particularly basal insulin)
   • Assess evening meal composition and timing
   • Consider physical activity from previous day
   • Evaluate alcohol consumption

3. Adjust treatment regimen to prevent future episodes:

   • Consider reducing evening/bedtime insulin doses
   • For patients with frequent nocturnal hypoglycemia, consider sensor-augmented insulin pump therapy with threshold-suspend feature 2
   • For patients with hypoglycemia unawareness, implement a 2-3 week period of scrupulous avoidance of hypoglycemia 3

Prevention Strategies

• Regular bedtime snack with complex carbohydrates and protein if needed 1
• More frequent blood glucose monitoring during the night for high-risk patients 2
• Consider technology solutions:
  • Continuous glucose monitoring with alarms
  • Insulin pumps with low-glucose suspend features 2
• Educate patients and caregivers on recognition of hypoglycemia symptoms and proper treatment 1
• Prescribe glucagon for all patients on insulin regimens 1

Special Considerations

• Nocturnal hypoglycemia is common (14-47% incidence) and may be asymptomatic 2
• Recurrent episodes can lead to hypoglycemia unawareness due to impaired counter-regulatory responses 3
• Risk factors include aggressive glycemic targets, alcohol consumption, exercise earlier in the day, and inconsistent meal timing 1

Remember that nocturnal hypoglycemia is a serious concern that requires both immediate treatment and long-term prevention strategies to reduce the risk of recurrence and complications.