Treatment for Recurrent Hypoglycemia
The first-line treatment for recurrent hypoglycemia involves administering 15-20g of fast-acting carbohydrates (preferably pure glucose) for conscious patients with blood glucose ≤70 mg/dL, followed by a meal or snack to prevent recurrence, while severe cases require glucagon administration. 1, 2
Immediate Management of Hypoglycemic Episodes
For Conscious Patients
- Administer 15-20g of glucose or carbohydrates when blood glucose is ≤70 mg/dL (3.9 mmol/L) 3, 2
- Pure glucose is the preferred treatment as it raises blood glucose more effectively than other carbohydrate sources 3, 1
- If glucose tablets are unavailable, alternative dietary sugars like Skittles, Mentos, sugar cubes, jelly beans, or orange juice can be used 3
- Recheck blood glucose 15 minutes after treatment; if hypoglycemia persists, repeat the treatment 3, 2
- Once blood glucose normalizes, consume a meal or snack containing carbohydrates to prevent recurrence 3, 1
- For patients using automated insulin delivery systems, a smaller amount (5-10g) of carbohydrates may be appropriate 2
For Severe Hypoglycemia (Altered Mental Status)
- Administer glucagon for patients unable or unwilling to consume oral carbohydrates 3, 4
- Glucagon should be prescribed for all individuals at risk of severe hypoglycemia 3, 5
- Available glucagon formulations include traditional reconstitution powder, intranasal glucagon, and ready-to-inject preparations 4, 6
- For adults and children weighing >25kg or ≥6 years with unknown weight, administer 1mg glucagon 5
- For children weighing <25kg or <6 years with unknown weight, administer 0.5mg glucagon 5
- If no response after 15 minutes, an additional dose may be administered while waiting for emergency assistance 5
Prevention of Recurrent Hypoglycemia
Identify and Address Risk Factors
- Regularly assess for risk factors including insulin use, poor glycemic control, albuminuria, and poor cognitive function 3, 1
- Understand situations that increase hypoglycemia risk: fasting, delayed meals, alcohol consumption, intense exercise, and sleep 3, 7
- Monitor blood glucose regularly using self-monitoring or continuous glucose monitoring (CGM) to detect incipient hypoglycemia 3, 8
Medication Adjustments
- Consider temporarily raising glycemic targets for patients with hypoglycemia unawareness or recurrent severe hypoglycemia 3, 9
- Several weeks of strict hypoglycemia avoidance can help reverse hypoglycemia unawareness 3
- Evaluate the need for medication adjustments after episodes of severe hypoglycemia 1, 7
- Consider newer diabetes medications with lower hypoglycemia risk (GLP-1 receptor agonists or SGLT2 inhibitors) for vulnerable patients 7
Education and Support
- Provide structured education on hypoglycemia prevention, recognition, and treatment 1, 7
- Instruct family members, caregivers, or others in close contact with at-risk individuals on glucagon administration 3, 4
- Teach patients to balance insulin use, carbohydrate intake, and physical activity 3, 8
Special Considerations
Choice of Carbohydrate Source
- Avoid carbohydrate sources high in protein as they may increase insulin secretion without adequately raising glucose 3, 2
- Added fat may slow and prolong the acute glycemic response 3, 2
- Glucose tablets or solution are more effective than glucose gel or orange juice in quickly alleviating symptoms 2, 10
Hypoglycemia Unawareness
- For patients with impaired hypoglycemia awareness, more vigilant monitoring and preventive strategies are essential 1, 9
- A 2-3 week period of scrupulous hypoglycemia avoidance is recommended to help restore awareness 3, 9
- Consider continuous glucose monitoring for patients with impaired awareness or frequent nocturnal hypoglycemia 7, 8