What is the immediate management for hypoglycemia (low blood sugar)?

Immediate Management 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

Recognition and Treatment Threshold

• Hypoglycemia is defined as blood glucose ≤70 mg/dL and requires immediate treatment 1, 2, 3
• Blood glucose <54 mg/dL represents clinically significant hypoglycemia where neuroglycopenic symptoms begin 3
• Even levels between 60-80 mg/dL may require management decisions such as carbohydrate ingestion in certain contexts 2

First-Line Treatment Protocol for Conscious Patients

Pure glucose is the preferred treatment because the glycemic response correlates better with glucose content than total carbohydrate content. 1, 2

Specific Treatment Options (in order of effectiveness):

• Glucose tablets or glucose solution are most effective and should be first-line 2, 4
• Any carbohydrate-containing food with glucose can be used as an alternative 1, 2
• Avoid orange juice and glucose gel as they are less effective in quickly alleviating symptoms compared to glucose tablets or solution 2, 4

Standard Dosing:

• Administer 15-20g of glucose orally for most patients 1, 2, 3
• For patients using automated insulin delivery systems, use a lower dose of 5-10g carbohydrates unless hypoglycemia occurs with exercise or after significant insulin overestimation 1, 2

Follow-Up Protocol:

• Recheck blood glucose 15 minutes after carbohydrate ingestion 1, 2, 3
• If hypoglycemia persists, repeat treatment with another 15-20g of carbohydrate 1, 2, 3
• Initial response should be seen within 10-20 minutes 2
• Evaluate blood glucose again 60 minutes after initial treatment 2

Critical Treatment Considerations

Do NOT use protein to treat hypoglycemia as it may increase insulin secretion and worsen the condition. 1, 2

• Adding fat to carbohydrate treatment may slow and prolong the acute glycemic response 2
• For patients taking α-glucosidase inhibitors, use ONLY glucose tablets or monosaccharides, as these drugs prevent digestion of complex carbohydrates and will delay treatment effectiveness 3
• Treating with foods high in protein without adequate glucose content can worsen hypoglycemia 1

Prevention of Recurrent Hypoglycemia

Once blood glucose returns to normal, the patient must consume a meal or snack with complex carbohydrates and protein to prevent recurrence. 1, 3

• Ensure patients at risk always carry fast-acting glucose sources such as glucose tablets, candy, or juice 2, 3
• Avoid targeting overly tight glucose control; aim to keep blood glucose >70 mg/dL 2

Severe Hypoglycemia (Unconscious or Unable to Take Oral Carbohydrates)

For patients unable or unwilling to consume carbohydrates orally, glucagon is the indicated treatment. 1, 2, 3

Glucagon Administration:

Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration. 2, 5

Dosing for Injectable Glucagon:

• Adults and children weighing >25 kg or ≥6 years: 1 mg (1 mL) subcutaneously or intramuscularly 6
• Children weighing <25 kg or <6 years: 0.5 mg (0.5 mL) subcutaneously or intramuscularly 6
• If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 7, 6

Post-Glucagon Care:

• Turn the patient on their side after glucagon administration to prevent choking if vomiting occurs 7
• When the patient awakens and can swallow, immediately give a fast-acting source of sugar (regular soft drink or fruit juice) followed by a long-acting source (crackers and cheese or meat sandwich) 7
• If the patient does not awaken within 15 minutes, give another dose of glucagon and call emergency services immediately 7

Glucagon Prescribing:

• All patients at risk for clinically significant hypoglycemia should be prescribed glucagon 3, 8
• Caregivers and family members must be instructed on glucagon administration, including where it is kept and when and how to administer it 9, 1, 3

Common Pitfalls to Avoid

• Failing to recheck blood glucose after initial treatment can lead to recurrent hypoglycemia 1
• Not carrying fast-acting glucose sources increases the risk of severe hypoglycemia 1
• Delaying treatment of hypoglycemia can lead to severe outcomes including seizures, unconsciousness, and death 3, 7
• Not adjusting insulin doses after hypoglycemic episodes perpetuates the problem 3

High-Risk Situations Requiring Extra Vigilance

Patients should understand situations that increase hypoglycemia risk: 9, 3

• Fasting for tests or procedures
• Delayed or skipped meals
• During and after intense exercise
• During and after alcohol consumption
• During sleep
• Declining renal function 3

When to Escalate Care

• Notify the physician whenever severe hypoglycemic reactions occur, even if glucagon successfully revives the patient 7
• For patients with recurrent hypoglycemia or hypoglycemia unawareness, raise glycemic targets for at least several weeks to reverse hypoglycemia unawareness and reduce future risk 3, 8
• Consider continuous glucose monitoring for patients with recurrent hypoglycemia 1, 8, 10