What are the guidelines for managing hypoglycemia?

Hypoglycemia Management Guidelines

For conscious patients with blood glucose <70 mg/dL, immediately administer 15-20 grams of oral glucose (preferably glucose tablets), recheck blood glucose in 15 minutes, and repeat treatment if hypoglycemia persists. 1, 2, 3

Classification of Hypoglycemia

Understanding the severity levels guides treatment urgency: 1, 2

• Level 1: Blood glucose <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L) - clinically important threshold requiring treatment 1
• Level 2: Blood glucose <54 mg/dL (3.0 mmol/L) - threshold where neuroglycopenic symptoms begin, requires immediate action 1
• Level 3: Severe hypoglycemia with altered mental/physical status requiring assistance from another person for recovery 1

Immediate Treatment Protocol

For Conscious Patients Who Can Swallow

Administer 15-20 grams of glucose orally as first-line treatment: 1, 2, 3

• Glucose tablets are the preferred form when available, as they provide more reliable and rapid glucose restoration compared to other dietary sugars 3
• Alternative options if glucose tablets unavailable: 1 tablespoon table sugar, 6-8 oz apple or orange juice, 6-8 oz regular soda, 1 tablespoon honey, or 15-25 jellybeans/gummy bears/hard candies 3

After initial treatment: 1, 2, 3

• Recheck blood glucose in 15 minutes 1, 3
• If blood glucose remains <70 mg/dL, repeat treatment with another 15-20 grams of glucose 1, 3
• Once blood glucose is trending upward, provide a meal or snack to prevent recurrence 1, 2

Special Consideration for α-Glucosidase Inhibitor Users

If the patient takes α-glucosidase inhibitors (acarbose, miglitol), use only monosaccharides such as glucose tablets - these drugs prevent digestion of polysaccharides, making complex carbohydrates ineffective for treating hypoglycemia 1

For Unconscious Patients or Those Unable to Swallow

Do NOT attempt oral glucose administration - this poses aspiration risk 3

Administer glucagon immediately: 1, 2, 4

• Adults and children >25 kg (or ≥6 years with unknown weight): 1 mg (1 mL) subcutaneously or intramuscularly into upper arm, thigh, or buttocks 4
• Children <25 kg (or <6 years with unknown weight): 0.5 mg (0.5 mL) subcutaneously or intramuscularly 4
• If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 4
• Call for emergency assistance immediately after administering glucagon 4

Glucagon Prescription Requirements

Prescribe glucagon for all individuals at increased risk of level 2 or 3 hypoglycemia so it is available when needed 1, 2

• Caregivers, school personnel, and family members must know where glucagon is stored and how to administer it 1, 2
• Glucagon administration is not limited to healthcare professionals - train lay caregivers 1, 2

Risk Assessment and Monitoring

Review occurrence and risk for hypoglycemia at every clinical encounter: 1, 2

• Screen for impaired hypoglycemia awareness at least annually using validated tools (Clarke score, Gold score, or Pedersen-Bjergaard score) 2
• Screen for fear of hypoglycemia in high-risk individuals at least annually 2
• Assess cognitive function regularly with increased vigilance for hypoglycemia if impairment is found 1, 2

Management of Hypoglycemia Unawareness and Recurrent Severe Hypoglycemia

For patients with hypoglycemia unawareness, one level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia: 1, 2

• Raise glycemic targets to strictly avoid hypoglycemia for at least several weeks - this partially reverses hypoglycemia unawareness and reduces risk of future episodes 1
• Provide hypoglycemia avoidance education 1, 2
• Reevaluate and adjust the treatment plan to decrease hypoglycemia 1, 2
• Consider deintensifying or switching diabetes medications 2

Prevention Strategies

Implement these measures to reduce hypoglycemia risk: 2, 5

• Consider continuous glucose monitoring (CGM) for all individuals at high risk for hypoglycemia, those with impaired hypoglycemia awareness, frequent nocturnal hypoglycemia, or history of severe hypoglycemia 2, 5
• Provide structured education on hypoglycemia prevention and treatment 2
• Implement standardized hospital-wide hypoglycemia treatment protocols for hospitalized patients 2

Common Pitfalls to Avoid

Critical errors that worsen outcomes:

• Never administer oral glucose to patients who are not awake or unable to swallow - this causes aspiration 3
• Do not use complex carbohydrates (starches) in patients taking α-glucosidase inhibitors - only monosaccharides like glucose tablets work 1
• Do not withhold basal insulin in type 1 diabetes patients even when taking nothing by mouth 2
• Avoid overtreating hypoglycemia with excessive carbohydrates, which leads to rebound hyperglycemia 1

Post-Treatment Follow-Up

After any severe hypoglycemia episode: 3, 5

• Reevaluate the entire diabetes management plan 3
• When the patient can swallow after glucagon administration, provide oral carbohydrates to restore liver glycogen and prevent recurrence 4
• For fasting patients after diagnostic procedures, give oral carbohydrates if compatible with the procedure 4