What are the steps for evaluating and managing hypoglycemia (low blood sugar)?

Evaluation and Management of Hypoglycemia

The recommended approach to hypoglycemia management involves prompt recognition, immediate treatment with 15-20g of glucose for conscious patients, and a systematic evaluation to prevent recurrence. 1, 2

Definition and Recognition

• Hypoglycemia is defined as blood glucose <70 mg/dL (<3.9 mmol/L), with severity classified in three levels 1:

  • Level 1: <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L)
  • Level 2: <54 mg/dL (3.0 mmol/L)
  • Level 3: Severe event requiring assistance, regardless of glucose level 1

• Review hypoglycemia history at every clinical encounter for all individuals at risk 1

• Screen for impaired hypoglycemia awareness at least annually using validated tools like Clarke score, Gold score, or Pedersen-Bjergaard score 1

• Common symptoms include shakiness, irritability, confusion, tachycardia, sweating, and hunger, but many patients may have impaired awareness 1, 3

Immediate Treatment Protocol

• For conscious patients with hypoglycemia (<70 mg/dL):

  • Administer 15-20g of glucose orally (glucose tablets or solution preferred) 1, 2
  • Recheck blood glucose after 15 minutes 1, 2
  • If hypoglycemia persists, repeat treatment with another 15-20g of glucose 2
  • Once blood glucose is trending up, provide a meal or snack to prevent recurrence 1

• For severe hypoglycemia (unconscious patient):

  • Administer glucagon via subcutaneous, intramuscular, or intravenous injection 4
  • For adults and children >25kg or ≥6 years: 1mg dose 4
  • For children <25kg or <6 years: 0.5mg dose 4
  • Call for emergency assistance immediately after administration 4
  • When patient responds and can swallow, give oral carbohydrates 4, 5

Comprehensive Evaluation

• Assess risk factors for hypoglycemia 1:

  • Medication use (insulin, sulfonylureas, meglitinides)
  • History of severe hypoglycemia or impaired awareness
  • Long duration of diabetes
  • Renal insufficiency
  • Recent changes in medication or insulin regimen

• Screen for fear of hypoglycemia in high-risk individuals at least annually 1

• Evaluate cognitive function regularly, with increased vigilance for hypoglycemia if impairment is found 1

• Review treatment regimen after any Level 2 or 3 hypoglycemic event 1

Prevention Strategies

• Consider continuous glucose monitoring (CGM) for individuals at high risk for hypoglycemia 1, 3

• Prescribe glucagon for all individuals taking insulin or at high risk for hypoglycemia 1

• Provide structured education on hypoglycemia prevention and treatment 1

• For patients with hypoglycemia unawareness or recent severe hypoglycemia:

  • Raise glycemic targets to strictly avoid hypoglycemia for several weeks to partially reverse unawareness 1
  • Consider deintensifying or switching diabetes medications 1

• In hospitalized patients, implement a standardized hospital-wide hypoglycemia treatment protocol 1

Special Considerations

• For patients with type 1 diabetes, never hold basal insulin even when taking nothing by mouth 1

• For patients transitioning from intravenous to subcutaneous insulin, administer basal insulin 2 hours before discontinuing IV infusion 1

• After apparent clinical recovery from hypoglycemia, continued observation and additional carbohydrate intake may be necessary to prevent recurrence 5

• For patients with recurrent hypoglycemia, consider newer diabetes medications with lower hypoglycemia risk (GLP-1 receptor agonists or SGLT2 inhibitors) rather than insulin when appropriate 3

By following this systematic approach to hypoglycemia evaluation and management, clinicians can effectively treat acute episodes and implement strategies to prevent future occurrences, ultimately reducing morbidity and mortality associated with hypoglycemia.