What is the management of recurrent hypoglycemia (low blood sugar)?

From the Guidelines

The management of recurrent hypoglycemia should prioritize immediate treatment with glucose and long-term prevention through adjustments in the treatment plan, including raising glycemic targets to avoid hypoglycemia, as recommended by the most recent guidelines 1. The immediate treatment of hypoglycemia (blood glucose <70 mg/dL) involves administering 15-20 grams of glucose, with the preferred treatment being glucose itself, although any form of carbohydrate containing glucose may be used 1.

• If the individual is conscious, they should consume the glucose and wait 15 minutes before rechecking their blood glucose levels.
• If hypoglycemia persists, the treatment should be repeated until blood glucose levels start to rise.
• Once the blood glucose levels are trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. For individuals at increased risk of level 2 or 3 hypoglycemia, glucagon should be prescribed and made available for administration by caregivers, school personnel, or family members, as it is not limited to healthcare professionals 1.

Long-term Management

Long-term management of recurrent hypoglycemia involves identifying and addressing underlying causes, such as excessive insulin dosing, and adjusting the treatment plan to decrease the risk of hypoglycemia.

• Insulin-treated patients with hypoglycemia unawareness or a history of level 3 hypoglycemic events should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks, as this can help partially reverse hypoglycemia unawareness and reduce the risk of future episodes 1.
• Ongoing assessment of cognitive function is also suggested, with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if impaired or declining cognition is found 1. Regular monitoring and adjustments to the treatment plan, including the use of continuous glucose monitoring systems, can help identify patterns and prevent episodes of hypoglycemia.

Prevention

Prevention of recurrent hypoglycemia is crucial, as it can lead to hypoglycemia unawareness due to blunted counter-regulatory hormone responses, creating a vicious cycle of increasingly severe episodes.

• Patients should be educated on hypoglycemia avoidance and the importance of regular meal timing, carbohydrate counting, and carrying fast-acting glucose sources 1.

From the FDA Drug Label

When the patient has responded to the treatment and is able to swallow, give oral carbohydrates to restore the liver glycogen and prevent recurrence of hypoglycemia. The management of recurrent hypoglycemia includes administering glucagon via injection and then giving oral carbohydrates to restore liver glycogen and prevent recurrence of hypoglycemia once the patient is able to swallow 2.

• Key steps:
  • Administer glucagon as soon as possible when severe hypoglycemia is recognized
  • Give oral carbohydrates after the patient responds to treatment and is able to swallow
  • Call for emergency assistance immediately after administering the dose Note that the diazoxide drug label does not provide direct information on the management of recurrent hypoglycemia 3.

From the Research

Management of Recurrent Hypoglycemia

The management of recurrent hypoglycemia involves several strategies, including:

• Recognition and immediate treatment of hypoglycemia in diabetic patients 4
• Use of oral glucose as the first-line treatment option for all conscious patients with hypoglycemia 4
• Use of glucagon as the second line of treatment (or first line in unconscious patients) 4
• Novel formulations of glucagon, such as nasal form, Gvoke HypoPen, and Dasiglucagon, which have recently been approved for the treatment of severe hypoglycemia 4
• Continuous glucose monitoring (CGM) to predict and prevent acute extreme changes in glycemic variability 5, 6
• Assessment of the patient's ability to proactively identify and manage hypoglycemia, and provision of education and support to reduce the risk of hypoglycemia 5, 6
• Optimization of insulin doses and carbohydrate intake, and consideration of physical activity sessions to avoid hypoglycemia 6
• Use of therapeutic considerations, such as administration of rapid-acting insulin analogues, pre-conception initiation of insulin analogues, and immediate postpartum insulin dose reduction, to reduce hypoglycemia risk during pregnancy 6

Prevention of Hypoglycemia

Prevention of hypoglycemia is also crucial, and can be achieved through:

• Evaluation and management of hypoglycemia only in patients in whom Whipple's triad is documented 7
• Pursuit of clinical clues to potential hypoglycemic etiologies, such as drugs, critical illnesses, hormone deficiencies, and nonislet cell tumors 7
• Measurement of plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia 7
• Practice of hypoglycemia risk factor reduction, addressing the issue of hypoglycemia, applying the principles of intensive glycemic therapy, and considering both conventional risk factors and those indicative of compromised defenses against falling plasma glucose concentrations 7
• Use of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) to decrease the number of patients at risk for hypoglycemia and reduce the impact of non-severe hypoglycemic events 8