What is the management of hypoglycemia?

Management of Hypoglycemia

The management of hypoglycemia requires prompt recognition and treatment with 15-20g of oral glucose for conscious patients, or glucagon administration for severe cases requiring assistance. 1

Definition and Recognition

• Hypoglycemia is defined as a blood glucose level <70 mg/dL (3.9 mmol/L) 1
• Severe hypoglycemia is characterized by altered mental status requiring assistance from another person and may include confusion, incoherence, combativeness, somnolence, lethargy, seizures, or coma 1
• Signs and symptoms can be confused with intoxication or withdrawal, particularly in settings like correctional institutions 1
• Common symptoms include shakiness, irritability, confusion, tachycardia, and hunger 1

Immediate Treatment Protocol

For Conscious Patients (Mild to Moderate Hypoglycemia)

• Administer 15-20g of oral glucose (preferred treatment) or any carbohydrate containing glucose 1
• Recheck blood glucose after 15 minutes 1
• If hypoglycemia persists, repeat the treatment 1
• Once blood glucose returns to normal (>70 mg/dL), the patient should consume a meal or snack to prevent recurrence 1

For Severe Hypoglycemia (Patient Requiring Assistance)

• Administer glucagon via intramuscular, subcutaneous, or intravenous injection 2
  • Adults and children >25kg or ≥6 years with unknown weight: 1mg dose 2
  • Children <25kg or <6 years with unknown weight: 0.5mg dose 2
• If no response after 15 minutes, an additional dose may be administered while waiting for emergency assistance 2
• After the patient regains consciousness, provide oral carbohydrates to restore liver glycogen and prevent recurrence 2

Special Considerations

Glucagon Administration

• Glucagon should be prescribed for all patients at risk for clinically significant hypoglycemia 1
• Caregivers, family members, school personnel, and others in close contact with patients should be instructed on glucagon administration 1
• For intranasal glucagon: As effective as injectable glucagon and easier to administer, particularly beneficial for caregivers with limited medical training 3

Prevention Strategies

• Identify patients at higher risk for hypoglycemia (those on insulin or sulfonylurea therapy) 1
• Implement systems for early detection and treatment 1
• Educate patients about situations that increase hypoglycemia risk:
  • Fasting for tests or procedures 1
  • Delayed meals 1
  • During or after exercise 1
  • During sleep 1
  • Alcohol consumption 1

Management of Recurrent Hypoglycemia

• For patients with hypoglycemia unawareness or recurrent severe episodes:
  • Raise glycemic targets for at least several weeks to reverse hypoglycemia unawareness and reduce risk of future episodes 1
  • Consider continuous glucose monitoring (CGM), particularly for those with impaired awareness 4
  • Review and adjust medication regimens, especially insulin dosing 1

Institutional Settings

• Train staff in recognition and treatment of hypoglycemia 1
• Implement protocols requiring notification of physicians for blood glucose results outside specified ranges (e.g., <50 or >350 mg/dL) 1
• Ensure immediate access to glucose tablets or other glucose-containing foods 1
• Have glucagon available for intramuscular injection or glucose for intravenous infusion 1
• Consider housing high-risk patients closer to medical units 1

Long-term Management

• Reevaluate diabetes management plan after any severe hypoglycemia or recurrent mild/moderate episodes 1
• Consider modern pharmaceutical options with lower hypoglycemia risk when appropriate 5
• Coordinate medication administration with meal timing to minimize risk 1
• Provide ongoing education and support for patients to become co-managers of their condition 5

Common Pitfalls to Avoid

• Failing to document blood glucose before treatment (attempt should be made when possible) 1
• Delaying treatment of hypoglycemia, which can lead to severe outcomes 1
• Not adjusting insulin doses after hypoglycemic episodes 1
• Overlooking the vicious cycle where antecedent hypoglycemia leads to impaired awareness and further episodes 6
• Neglecting the psychological impact of hypoglycemia, including fear that may lead to intentional hyperglycemia 5
• Using sliding scale insulin as the sole insulin regimen, which is strongly discouraged 1