Management of Hypoglycemia Following Insulin Administration
Immediate treatment of hypoglycemia (blood glucose <70 mg/dL) requires administration of 15-20 g of glucose, followed by reassessment after 15 minutes and repeated treatment if hypoglycemia persists. 1
Immediate Management of Hypoglycemia
For Conscious Patients
- Administer 15-20 g of glucose orally (preferred treatment) or any form of carbohydrate containing glucose 1
- Recheck blood glucose after 15 minutes; if hypoglycemia persists, repeat treatment 1
- Once blood glucose returns to normal, the patient should consume a meal or snack to prevent recurrence of hypoglycemia 1
- Pure glucose provides the best acute glycemic response, though any carbohydrate containing glucose will raise blood glucose 1
For Severe Hypoglycemia (Patient Unable to Self-Treat)
- Administer glucagon immediately via subcutaneous or intramuscular injection into the upper arm, thigh, or buttocks 2
- For adults and children weighing >25 kg or ≥6 years with unknown weight: administer 1 mg (1 mL) 2
- For children weighing <25 kg or <6 years with unknown weight: administer 0.5 mg (0.5 mL) 2
- If no response after 15 minutes, a second dose may be administered while waiting for emergency assistance 2
- After the patient regains consciousness, oral carbohydrates must be given to restore liver glycogen and prevent recurrence 2, 3
Hospital Setting Management
- A standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be implemented to immediately address hypoglycemia 1
- For blood glucose <3.3 mmol/L (60 mg/dL), administer glucose immediately even in the absence of symptoms 1
- For blood glucose between 3.8-5.5 mmol/L (70-100 mg/dL) with symptoms of hypoglycemia, glucose should be administered 1
- In unconscious patients or those unable to swallow, intravenous glucose should be administered immediately 1
- After regaining consciousness, oral glucose administration should follow 1
Prevention of Recurrent Hypoglycemia
- After apparent clinical recovery, continued observation and additional carbohydrate intake may be necessary to prevent recurrence 3
- Patients with hypoglycemia unawareness or history of severe hypoglycemia should temporarily raise their glycemic targets for several weeks to partially reverse hypoglycemia unawareness 1
- Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia 1
- Family members, roommates, school personnel, caregivers, or coworkers should be instructed in glucagon administration 1
- All insulin users should carry medical identification (bracelet or wallet card) 1
Special Considerations
Causes of Insulin-Induced Hypoglycemia
- Excess insulin relative to food intake or energy expenditure 3
- Delayed or missed meals 1
- Decreased carbohydrate content of a meal 1
- Increased physical activity 1
- Increased insulin absorption rates (e.g., due to increased skin temperature) 1
Risk Factors for Severe Hypoglycemia
- Hypoglycemia unawareness 1, 4
- Nocturnal hypoglycemia 4
- Intensive insulin management 4
- Advanced age 1
- Renal failure 1
- Poor oral intake 1
Long-Term Management
- For patients with recurrent hypoglycemia, consider adjusting insulin regimen 5
- Balance basal and meal insulin therapy to reduce glycemic variability 5
- Frequent blood glucose monitoring, including consideration of continuous glucose monitoring for those with hypoglycemia unawareness 5
- Severe or frequent hypoglycemia is an absolute indication for modification of treatment regimens 1
Emerging Therapies
- Novel formulations of glucagon including nasal form, ready-to-deliver auto-injectors, and glucagon analogues are becoming available 6
- Continuous glucose monitoring and sensor-augmented pump therapy have made significant improvements in helping to reduce and prevent hypoglycemia 6
Remember that prevention of hypoglycemia is a critical component of diabetes management 1, and fear of hypoglycemia often leads patients to avoid following or adjusting their insulin regimens appropriately 4.