What are the recommendations for treatment of hypoglycemia (low blood glucose)?

Treatment Recommendations for Low Blood Glucose (Hypoglycemia)

For individuals with suspected hypoglycemia who are awake and able to swallow, oral glucose (15-20g) is the preferred treatment and should be administered immediately. 1

Definition and Classification of Hypoglycemia

Hypoglycemia is defined by blood glucose levels:

• Level 1: <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L) 1
• Level 2: <54 mg/dL (3.0 mmol/L) 1
• Level 3: Severe event characterized by altered mental/physical status requiring assistance 1

First-Line Treatment for Conscious Individuals

Preferred Treatment Options (in order of preference):

1. Glucose tablets (15-20g) - Most effective and preferred option 1
2. Simple dietary sugars - Reasonable alternative when glucose tablets are unavailable 1

Dietary Sources Containing Approximately 15g of Simple Sugars:

• 1 tablespoon table sugar 1
• 6-8 oz apple or orange juice 1
• 6-8 oz regular (non-diet) soda 1
• 1 tablespoon honey 1
• 15-25 jellybeans, gummy bears, or hard-shelled candies 1

Treatment Protocol

1. Initial treatment: Administer 15-20g of glucose orally for conscious individuals with suspected hypoglycemia 1
2. Reassessment: Check blood glucose 15 minutes after treatment 1
3. Repeat treatment: If hypoglycemia persists after 15 minutes, repeat the treatment with another 15-20g of glucose 1
4. Follow-up meal: Once blood glucose is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia 1

Special Considerations

For Children:

• For children who are awake but unwilling or unable to swallow glucose, it may be reasonable to apply a slurry of granulated sugar and water under the tongue 1

For Severe Hypoglycemia (Unable to Swallow):

• Do not administer oral glucose to people who are not awake or unable to swallow 1
• Glucagon should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia 1, 2
• For adults and children >25kg or ≥6 years: 1mg glucagon injected subcutaneously or intramuscularly 2
• For children <25kg or <6 years: 0.5mg glucagon injected subcutaneously or intramuscularly 2
• Emergency medical services should be activated immediately 1, 2

When to Seek Emergency Medical Assistance

Activate emergency medical services for hypoglycemia when:

• The person is unable to swallow 1
• The person has a seizure 1
• The person does not improve within 10 minutes of oral glucose administration 1
• The person has level 3 hypoglycemia (severe, requiring assistance) 1

Important Clinical Considerations

Prevention of Recurrent Hypoglycemia:

• For patients with hypoglycemia unawareness or recurrent level 2/3 hypoglycemia, consider raising glycemic targets temporarily to avoid hypoglycemia for several weeks 1
• This approach can help partially reverse hypoglycemia unawareness and reduce risk of future episodes 1, 3

Common Pitfalls to Avoid:

• Delayed treatment: Prompt treatment is essential to prevent progression to severe hypoglycemia 1, 3
• Inadequate follow-up: Failure to consume a meal after initial treatment can lead to recurrent hypoglycemia 1
• Overtreatment: Providing excessive carbohydrates can lead to rebound hyperglycemia 1
• Using inappropriate treatments: Administering oral treatments to unconscious patients risks aspiration 1

Recent Evidence

Recent research suggests that treating impending hypoglycemia at slightly higher blood glucose levels (≤80 or ≤90 mg/dL) with 16g carbohydrates may reduce the occurrence and duration of hypoglycemic events compared to waiting until glucose falls below 70 mg/dL 4. However, current guidelines still recommend initiating treatment when blood glucose is <70 mg/dL 1.