What is the management of acute hypoglycemia?

Management of Acute Hypoglycemia

For conscious patients with hypoglycemia (blood glucose ≤70 mg/dL), immediately administer 15-20g of pure glucose orally, recheck blood glucose in 15 minutes, and repeat treatment if hypoglycemia persists; for unconscious patients or those unable to swallow, administer glucagon via intranasal, subcutaneous, or intramuscular route. 1, 2

Recognition and Definition

• Hypoglycemia is defined as blood glucose ≤70 mg/dL and requires prompt treatment 1, 2
• Even levels between 60-80 mg/dL may warrant carbohydrate ingestion 1
• Symptoms include sweating, tremor, palpitations, confusion, altered mental status, and in severe cases, seizures or unconsciousness 3

Treatment Protocol for Conscious Patients

First-Line Treatment

• Administer 15-20g of glucose orally as the preferred treatment 4, 1, 2
• Pure glucose (tablets or solution) is superior because glycemic response correlates better with glucose content than total carbohydrate content 1, 5
• Any carbohydrate containing glucose can be used if glucose tablets are unavailable 1, 5

Special Dosing Considerations

• Patients using automated insulin delivery systems may only require 5-10g of carbohydrates, unless hypoglycemia occurs with exercise or after significant insulin overestimation 1, 2
• This lower dose reflects the system's ability to reduce or suspend insulin delivery 1

Monitoring and Repeat Treatment

• Recheck blood glucose 15 minutes after carbohydrate administration 4, 1, 5
• If hypoglycemia persists, repeat treatment with another 15-20g of carbohydrate 4, 1, 5
• Initial response should occur within 10-20 minutes 1, 5
• Evaluate blood glucose again 60 minutes after initial treatment 1

Prevention of Recurrence

• Once blood glucose normalizes, have the patient consume a meal or snack containing complex carbohydrates and protein to prevent recurrence 4, 2
• This step is critical because ongoing insulin or insulin secretagogue activity can cause hypoglycemia to recur 4

What NOT to Use

• Do not use protein alone to treat hypoglycemia, as it may increase insulin secretion without raising blood glucose 1, 2
• Avoid adding fat to initial treatment, as it slows and prolongs the glycemic response 4, 1
• Orange juice and glucose gel are less effective than glucose tablets or solution 1

Treatment Protocol for Unconscious Patients (Severe Hypoglycemia)

Glucagon Administration

• For patients unable or unwilling to consume oral carbohydrates, glucagon is the treatment of choice 1, 2
• Newer intranasal and ready-to-inject subcutaneous formulations are preferred over traditional injectable glucagon due to ease of administration 1, 6
• Traditional injectable glucagon requires reconstitution, which can be difficult in emergency situations 7, 8

Dosing by Age and Weight

Adults and children weighing >25 kg or ≥6 years of age:

• Administer 1 mg (1 mL) subcutaneously, intramuscularly, or intravenously 9
• If no response after 15 minutes, administer an additional 1 mg dose using a new kit while waiting for emergency assistance 9

Children weighing <25 kg or <6 years of age:

• Administer 0.5 mg (0.5 mL) subcutaneously, intramuscularly, or intravenously 9
• If no response after 15 minutes, administer an additional 0.5 mg dose using a new kit while waiting for emergency assistance 9

Post-Glucagon Care

• Turn the patient on their side after glucagon administration to prevent choking if vomiting occurs 3
• Nausea and vomiting are common side effects of glucagon 9, 3, 8
• When the patient awakens and can swallow, immediately give oral carbohydrates (fast-acting sugar followed by complex carbohydrates) 9, 3
• Call for emergency medical assistance immediately after administering glucagon, even if the patient responds 9, 3

Comparative Efficacy

• Both intravenous glucagon and dextrose are effective for severe hypoglycemia, though recovery of consciousness is slower with glucagon (6.5 minutes) compared to dextrose (4.0 minutes) 10
• However, glucagon has advantages in ease of administration and lower risk of vascular complications when IV access is not available 10

Glucagon Prescribing and Education

• All individuals at significant risk of severe hypoglycemia should be prescribed glucagon 4, 2
• Family members, caregivers, school personnel, and others in close contact must be instructed in glucagon administration 4, 2
• Healthcare professional status is not required to safely administer glucagon 4
• Ensure unexpired glucagon kits are always available 4

Prevention Strategies

• Patients at risk should always carry fast-acting glucose sources (glucose tablets or candy) 2, 3
• Avoid prolonged fasting periods 2
• Implement consistent meal timing when using fixed insulin regimens 2
• Include protein and/or fat with meals to slow carbohydrate absorption 2
• Consider continuous glucose monitoring for patients with recurrent hypoglycemia 2

Management of Hypoglycemia Unawareness

• Patients with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks 4
• This approach can partially reverse hypoglycemia unawareness and reduce risk of future episodes 4

Critical Pitfalls to Avoid

• Never delay treatment of hypoglycemia, as even mild hypoglycemia can rapidly progress to severe hypoglycemia 5
• Do not fail to recheck blood glucose after initial treatment, as this can lead to recurrent hypoglycemia 2
• Do not proceed with any medical procedures or evaluations during active hypoglycemia, as altered mental status invalidates assessment results and poses safety risks 5
• Avoid treating with high-protein foods without adequate glucose content, as this can worsen the condition 2