What is the treatment for hypoglycemia?

Treatment of Hypoglycemia

For conscious patients with hypoglycemia (blood glucose ≤70 mg/dL), immediately administer 15-20g of oral glucose, recheck blood glucose after 15 minutes, and repeat treatment if hypoglycemia persists. 1, 2

Immediate Treatment Protocol for Conscious Patients

Pure glucose is the preferred first-line treatment because the glycemic response correlates better with glucose content than with total carbohydrate content. 3, 1 Glucose tablets or glucose solution are the most effective options. 1

Standard Dosing Algorithm:

• Adults and children >25 kg (or ≥6 years): Administer 15-20g of glucose orally 3, 1, 2
• Children <25 kg (or <6 years): Administer 0.5 mg glucagon subcutaneously/intramuscularly 4
• Patients on automated insulin delivery systems: Consider lower dose of 5-10g carbohydrates unless hypoglycemia occurs with exercise or after significant insulin overestimation 1, 5

Follow-Up Protocol:

• Initial response should occur within 10-20 minutes 3, 1
• Recheck blood glucose 15 minutes after treatment 3, 1, 2
• If hypoglycemia persists, repeat with another 15-20g of carbohydrate 3, 1, 2
• Evaluate blood glucose again at 60 minutes as additional treatment may be necessary 3, 1
• Once blood glucose normalizes, provide a meal or snack with complex carbohydrates and protein to prevent recurrence 2, 5

Treatment Options and Effectiveness

While any carbohydrate-containing food with glucose can be used 3, 1, glucose tablets or solution are superior to orange juice or glucose gel for rapid symptom relief. 1 The glucose content of 10g can raise blood glucose by approximately 40 mg/dL over 30 minutes, while 20g raises it by 60 mg/dL over 45 minutes. 3

Important Considerations:

• Adding fat to treatment slows and prolongs the glycemic response and should be avoided during acute treatment 3, 1
• Protein should NOT be used to treat hypoglycemia as it may increase insulin secretion without providing adequate glucose 1, 5
• Adding protein to carbohydrate treatment does not prevent subsequent hypoglycemia 3

Treatment for Severe Hypoglycemia (Unconscious Patients)

For patients unable or unwilling to consume oral carbohydrates, glucagon is indicated. 1, 2, 5

Glucagon Administration:

• Adults and children >25 kg (or ≥6 years): 1 mg (1 mL) subcutaneously, intramuscularly, or intravenously 4
• Children <25 kg (or <6 years): 0.5 mg (0.5 mL) subcutaneously, intramuscularly, or intravenously 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

Newer intranasal and ready-to-inject glucagon preparations are now preferred due to ease of administration and better compliance. 1, 6 These formulations do not require reconstitution, making them more practical for emergency use. 6

Post-Glucagon Care:

• When the patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence 4
• Sustained carbohydrate intake and observation are necessary because hypoglycemia may recur after apparent clinical recovery 7

Special Populations and Risk Factors

High-risk patients include those with advanced age (>60 years), history of hypoglycemia unawareness, prior severe hypoglycemia episodes, and those on insulin or sulfonylureas. 2

Pediatric Considerations:

• Young children with type 1 diabetes are particularly vulnerable due to reduced ability to recognize symptoms 5
• Prolonged and recurrent severe hypoglycemia in younger children can cause permanent neuropsychological dysfunction including learning disabilities 8

Medication-Related Causes:

• Insulin and sulfonylureas are the most common medication-related causes 2, 5
• Sulfonylureas have the highest risk among oral agents 2
• Alpha-glucosidase inhibitors require treatment with monosaccharides (glucose tablets) as they prevent digestion of polysaccharides 3

Prevention Strategies

All patients at risk should have access to glucose tablets or glucose-containing foods at all times. 1, 2

Key Prevention Measures:

• Avoid targeting overly tight glucose control; maintain blood glucose >70 mg/dL 1
• For patients with hypoglycemia unawareness, raise glycemic targets for several weeks to reverse unawareness and reduce future risk 2
• Educate patients about high-risk situations: fasting for tests, delayed meals, exercise, sleep, and alcohol consumption 2, 5
• Coordinate medication administration with meal timing 2
• Consider continuous glucose monitoring for those with recurrent hypoglycemia 5, 6

Family and Caregiver Education:

• All family members and caregivers should be instructed on glucagon administration 2, 5
• Patients should inform those around them about their condition and emergency treatment 4

Common Pitfalls to Avoid

• Do NOT treat with protein-containing foods without adequate glucose as this can worsen hypoglycemia 1, 5
• Do NOT fail to recheck blood glucose after initial treatment as this leads to recurrent hypoglycemia 5
• Do NOT delay treatment as this can lead to severe outcomes including seizures and coma 2
• Do NOT use sliding scale insulin as the sole insulin regimen as this is strongly discouraged 2
• Do NOT skip meals when on premixed or fixed insulin regimens to reduce hypoglycemia risk 3