What is the protocol for treating hypoglycemia (low blood sugar)?

Hypoglycemia Treatment Protocol

For conscious patients with hypoglycemia (blood glucose <70 mg/dL), immediately administer 15-20 grams of oral glucose, recheck blood glucose after 15 minutes, and repeat treatment if hypoglycemia persists; for unconscious patients or those unable to swallow, administer glucagon immediately. 1, 2

Immediate Treatment for Conscious Patients

First-Line Therapy: The "15-15 Rule"

• Administer 15-20 grams of glucose orally as soon as hypoglycemia is recognized (blood glucose <70 mg/dL or 3.9 mmol/L). 1, 2
• Pure glucose tablets or glucose solution are preferred over other carbohydrate sources because the glycemic response correlates better with glucose content than total carbohydrate content. 2
• Any carbohydrate-containing food with glucose may be used if glucose tablets are unavailable, though orange juice and glucose gel are less effective at quickly alleviating symptoms. 1, 2

Monitoring and Repeat Treatment

• Recheck blood glucose 15 minutes after carbohydrate ingestion. 1, 2
• If blood glucose remains <70 mg/dL, repeat treatment with another 15-20 grams of carbohydrate. 1
• Continue this cycle until blood glucose trends upward and normalizes. 1
• Evaluate blood glucose again 60 minutes after initial treatment to ensure sustained recovery. 2

Post-Recovery Meal

• Once blood glucose normalizes, provide a meal or snack to restore liver glycogen and prevent recurrence of hypoglycemia. 1, 3, 4
• This step is critical—do not skip it even if the patient feels better. 3

Special Considerations for Carbohydrate Treatment

Patients on α-Glucosidase Inhibitors

• Use monosaccharides such as glucose tablets specifically, as these medications prevent digestion of polysaccharides (complex carbohydrates). 1
• Regular table sugar or complex carbohydrates will not work effectively in these patients. 1

Patients Using Automated Insulin Delivery Systems

• A lower dose of 5-10 grams of carbohydrates may be appropriate unless hypoglycemia occurs with exercise or after significant insulin overestimation. 2

What NOT to Use

• Avoid protein for treating hypoglycemia as it may increase insulin secretion and worsen the situation. 2
• Avoid adding fat to carbohydrate treatment as it slows and prolongs the acute glycemic response, delaying recovery. 2

Treatment for Severe Hypoglycemia (Unconscious or Unable to Swallow)

Glucagon Administration

• Glucagon should be prescribed for all individuals at increased risk of level 2 (glucose <54 mg/dL) or level 3 (severe event requiring assistance) hypoglycemia. 1
• Administer glucagon immediately when the patient is unconscious, having seizures, or unable/unwilling to consume oral carbohydrates. 2, 4
• Glucagon administration is not limited to healthcare professionals—caregivers, family members, and school personnel should know where it is and how to administer it. 1

Dosing Guidelines for Glucagon

Adults and children weighing >25 kg (or age ≥6 years with unknown weight):

• Administer 1 mg (1 mL) subcutaneously, intramuscularly, or intravenously. 4
• If no response after 15 minutes, administer an additional 1 mg dose using a new kit while waiting for emergency assistance. 4

Children weighing <25 kg (or age <6 years with unknown weight):

• Administer 0.5 mg (0.5 mL) subcutaneously, intramuscularly, or intravenously. 4
• If no response after 15 minutes, administer an additional 0.5 mg dose using a new kit while waiting for emergency assistance. 4

Post-Glucagon Care

• Call for emergency assistance immediately after administering glucagon. 4
• When the patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence. 4

Newer Glucagon Formulations

• Intranasal glucagon and ready-to-inject auto-injector formulations (Gvoke HypoPen, Dasiglucagon) are now preferred due to ease of administration and no need for reconstitution. 2, 5
• These formulations ensure better compliance and faster administration in emergency situations. 5

Intravenous Treatment (Healthcare Settings)

• For severe hypoglycemia with altered mental status, administer 10-20 grams of intravenous 50% dextrose immediately. 3
• Recheck blood glucose every 15 minutes until levels exceed 70 mg/dL. 3
• Stop any insulin infusion immediately if present. 3
• Avoid overcorrection causing iatrogenic hyperglycemia. 3

Classification of Hypoglycemia Severity

Understanding these levels helps guide treatment intensity:

• Level 1: Glucose <70 mg/dL but ≥54 mg/dL—treat with oral glucose. 1
• Level 2: Glucose <54 mg/dL—more urgent, requires immediate treatment. 1
• Level 3: Severe event with altered mental/physical status requiring assistance—requires glucagon or IV dextrose. 1

Prevention and Follow-Up

Immediate Risk Assessment

• Review occurrence and risk for hypoglycemia at every clinical encounter. 1
• Hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should trigger immediate hypoglycemia avoidance education and reevaluation of the medical regimen. 1

Reversing Hypoglycemia Unawareness

• Patients with hypoglycemia unawareness should raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks to partially reverse unawareness and reduce future risk. 1
• This 2-3 week period of scrupulous hypoglycemia avoidance is critical for restoring awareness. 6

Patient Education Essentials

• Ensure all at-risk patients carry glucose tablets or glucose-containing foods at all times. 2
• Physical activity may result in low blood glucose—patients should always carry a carbohydrate source during and after exercise. 1
• Alcohol should be consumed with food to reduce hypoglycemia risk in patients on insulin or insulin secretagogues. 1
• Do not skip meals if on insulin secretagogues or fixed insulin regimens. 1

Common Pitfalls to Avoid

• Do not use complex carbohydrates or protein as first-line treatment—they work too slowly. 2
• Do not delay glucagon administration in unconscious patients while attempting oral treatment—this wastes critical time. 4
• Do not forget the post-recovery meal—many patients experience rebound hypoglycemia without it. 3, 4
• Do not overtighten glycemic targets in patients with recurrent hypoglycemia—aim to keep blood glucose >70 mg/dL. 2