What is the appropriate workup and management for a patient presenting with hypoglycemia (low blood sugar)?

Hypoglycemia Workup and Management

Immediately check capillary blood glucose when hypoglycemia is suspected, and if <70 mg/dL (3.9 mmol/L), treat first before completing any extensive workup. 1

Initial Assessment and Diagnosis

Immediate Glucose Measurement

• Measure capillary blood glucose immediately when any symptom suggestive of hypoglycemia is present 1
• Document the glucose level before treatment whenever possible 1
• Treat immediately if glucose is <70 mg/dL (3.9 mmol/L), even before completing a full diagnostic evaluation 1

Classify Hypoglycemia Severity

• Level 1: Glucose <70 mg/dL (3.9 mmol/L) and ≥54 mg/dL (3.0 mmol/L) - alerts to take action 1
• Level 2: Glucose <54 mg/dL (3.0 mmol/L) - requires immediate treatment as neuroglycopenic symptoms begin 1
• Level 3 (Severe): Patient requires assistance from another person due to cognitive impairment, confusion, combativeness, somnolence, lethargy, seizures, or coma 1

Symptom Assessment

• Neurogenic symptoms: Shakiness, diaphoresis, palpitations, anxiety 1
• Neuroglycopenic symptoms: Confusion, altered mental status, agitation, difficulty concentrating, seizures, or coma 1
• Note that symptoms may occur at higher glucose levels in individuals with poor glycemic control 2

Acute Treatment Protocol

Conscious Patients (Able to Swallow)

• Administer 15-20 grams of oral glucose immediately 1
• Pure glucose is preferred, though any carbohydrate containing glucose will work 1
• Avoid adding fat or protein as these delay glycemic response 1
• Recheck blood glucose after 15 minutes 1
• If hypoglycemia persists, repeat the 15-20 gram glucose dose 1

Unconscious Patients or Unable to Swallow

• Administer intravenous glucose immediately 1, 3
• Glucagon administration (intramuscular or subcutaneous) 1, 4:
  • Adults and children >25 kg or ≥6 years: 1 mg (1 mL) 4
  • Children <25 kg or <6 years: 0.5 mg (0.5 mL) 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

Post-Recovery Care

• When the patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence 4, 3
• Continued observation and additional carbohydrate intake may be necessary to avoid reoccurrence 3

Post-Acute Workup and Risk Assessment

Identify High-Risk Features

• Endogenous insulin deficiency (advanced diabetes) 5
• History of severe hypoglycemia or hypoglycemia unawareness 5, 2
• Strict glycemic control with lower HbA1c levels 6, 5
• High glycemic variability 6
• Long duration of disease or insulin therapy 6
• Recent antecedent hypoglycemia (creates a vicious cycle of recurrent episodes) 5

Medication Review

• Insulin excess: Review dose, timing, and type 5
• Sulfonylureas or glinides: Associated with increased hypoglycemia risk 7, 2
• Patterns of food ingestion and exercise 5
• Interactions with alcohol and other drugs 5
• Consider switching to basal insulin analogues (vs. NPH), rapid-acting insulin analogues (vs. regular human insulin), or premix insulin analogues to reduce hypoglycemia risk 6

Determine Need for Admission

• Consider admission for unexplained or recurrent severe hypoglycemia for observation and stabilization 1
• Any episode of severe hypoglycemia or recurrent mild-moderate episodes requires reevaluation of the diabetes management plan 1

Prevention Strategy

Hypoglycemia Unawareness Management

• Implement a 2-3 week period of scrupulous hypoglycemia avoidance by raising glycemic targets for patients with hypoglycemia unawareness 1, 5
• This reverses hypoglycemia unawareness in most affected patients 5
• Consider continuous glucose monitoring (CGM) for all individuals with increased risk, impaired hypoglycemia awareness, frequent nocturnal hypoglycemia, or history of severe hypoglycemia 2

Treatment Regimen Modification

• Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification 1
• Avoid sliding-scale insulin as sole therapy 1
• Consider newer anti-diabetic drugs (GLP-1 receptor agonists or SGLT2 inhibitors) for vulnerable patients at dual risk of severe hypoglycemia and cardiovascular outcomes 2

Patient and Caregiver Education

• Train patients and caregivers on recognition of unique signs and symptoms of hypoglycemia 1
• Educate on situations increasing hypoglycemia risk 1
• Teach proper treatment techniques 1
• All patients at risk for severe hypoglycemia should be prescribed glucagon, and caregivers must be trained in its administration 1, 8
• Administer patient questionnaires at each visit to enable accurate reporting of hypoglycemia 6

Lifestyle Modifications

• Optimize insulin doses and carbohydrate intake 2
• Consider a short warm-up before or after physical activity sessions 2
• Provide dietary intervention and exercise counseling 6

Critical Pitfalls to Avoid

• Do not delay treatment to complete a full workup - treat first when glucose is <70 mg/dL 1
• Do not add fat or protein to acute glucose treatment as this delays response 1
• Do not underutilize glucagon - it is safe, efficacious, but frequently undertaught and underutilized 8
• Do not ignore recurrent mild-moderate episodes - these require management plan reevaluation 1
• Recognize that hypoglycemia unawareness creates a vicious cycle through hypoglycemia-associated autonomic failure 5