Is sublingual lubrication of wetted table sugar effective in treating hypoglycemia in a confused patient when intravenous (IV) glucose or intramuscular (IM) glucagon is not available?

Sublingual Sugar Administration for Hypoglycemia in Confused Patients

Sublingual administration of wetted table sugar can be effective in treating hypoglycemia in confused patients when IV glucose or IM glucagon is not available, particularly in resource-limited settings. 1

Evidence for Sublingual Sugar Administration

• One randomized controlled trial showed that sublingual sugar administration (2.5g of wet sugar under the tongue) resulted in significantly higher blood glucose concentrations at 20 minutes compared to oral administration in children 1
• Sublingual sugar administration demonstrated a significant decrease in time to resolution of hypoglycemia compared to oral administration 1
• Patients receiving sublingual sugar had a higher likelihood of resolution of hypoglycemia (reaching blood glucose ≥90 mg/dL) within 80 minutes compared to oral administration 1
• No adverse events were reported with sublingual sugar administration in studies 1

Clinical Application Algorithm

When to Use Sublingual Sugar:

1. Patient assessment:

   • Patient is confused but still conscious 1
   • IV glucose and IM glucagon are unavailable 1
   • Patient may be uncooperative with swallowing 1

2. Administration technique:

   • Apply approximately 2.5g of table sugar (about 1/2 teaspoon) moistened with water under the tongue 1
   • Ensure sugar remains under the tongue for absorption 1

3. Monitoring:

   • Observe for improvement in mental status 1
   • If available, check blood glucose after 20 minutes 1
   • If no improvement within 10 minutes, seek emergency medical services 1

Comparative Effectiveness:

• For patients who can swallow, oral/swallowed glucose remains the first-line recommendation 1
• Buccal glucose administration (placed against the cheek) is less effective than oral/swallowed glucose 1
• Sublingual administration appears more effective than buccal administration, particularly in uncooperative patients 1

Important Considerations and Cautions

• Safety profile: No adverse events were reported in studies of sublingual sugar administration 1
• Aspiration risk: Ensure patient has intact airway protective reflexes; do not administer to unconscious patients 1
• Limited evidence base: Evidence comes primarily from one study in children with malaria or respiratory infections; broader applicability remains uncertain 1
• Dosing: The effective dose studied was 2.5g of wetted sugar under the tongue 1
• Follow-up care: Once the patient improves, transition to oral carbohydrates when possible 1
• Seek advanced care: If the patient does not improve, remains confused, or deteriorates, emergency medical services should be contacted immediately 1

Special Populations

• Children: Sublingual sugar may be particularly useful in children who are uncooperative with oral administration 1
• Resource-limited settings: This approach is especially valuable in settings without access to medical facilities or emergency services 1
• Diabetes patients: Those with recurrent hypoglycemia may benefit from having family members educated on this technique for emergency use 2, 3