What is the immediate management of diabetic hypoglycemia?

Immediate Management of Diabetic Hypoglycemia

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

Recognition and Definition

• Hypoglycemia is defined as blood glucose ≤70 mg/dL and requires immediate treatment regardless of symptom severity. 1, 2
• Clinically significant hypoglycemia occurs at <54 mg/dL, where neuroglycopenic symptoms begin and urgent intervention is required. 3
• Severe hypoglycemia is characterized by altered mental or physical status requiring assistance from another person. 2, 3
• Document blood glucose before treatment whenever possible, though treatment should never be delayed while waiting for confirmation. 4, 3

Immediate Treatment Protocol for Conscious Patients

First-Line Treatment (Oral Glucose)

• Administer 15-20 grams of fast-acting carbohydrate immediately when blood glucose is ≤70 mg/dL. 1, 2, 3
• Pure glucose tablets or glucose solution are the most effective treatment options because the glycemic response correlates better with glucose content than total carbohydrate content. 1
• Alternative carbohydrate sources include 4 ounces of fruit juice, 4 ounces of regular soda, or hard candy. 3
• Orange juice and glucose gel are less effective in quickly alleviating symptoms compared to glucose tablets or solution. 1, 5

Treatment Response and Follow-Up

• Recheck blood glucose exactly 15 minutes after carbohydrate ingestion. 1, 2
• Initial response to treatment should be seen within 10-20 minutes. 1
• If blood glucose remains <70 mg/dL after 15 minutes, repeat treatment with another 15-20 grams of carbohydrate. 1, 2
• Evaluate blood glucose again 60 minutes after initial treatment. 1
• Once blood glucose returns to normal (≥70 mg/dL), the patient should consume a meal or snack to prevent recurrence. 2

Special Dosing Considerations

• For 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. 1
• Avoid adding fat to carbohydrate treatment as it may slow and prolong the acute glycemic response. 1
• Do not use protein to treat hypoglycemia as it may increase insulin secretion. 1

Treatment for Severe Hypoglycemia (Unconscious or Unable to Swallow)

Glucagon Administration

• For patients unable or unwilling to consume carbohydrates orally, glucagon is indicated immediately. 1, 2
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration. 1, 6

Dosing Guidelines

• Adults and children weighing >25 kg or ≥6 years old: Administer 1 mg (1 mL) subcutaneously, intramuscularly, or intravenously. 1, 6
• Children weighing <25 kg or <6 years old: Administer 0.5 mg (0.5 mL) subcutaneously, intramuscularly, or intravenously. 1, 6
• If there is no response after 15 minutes, an additional dose may be administered using a new kit while waiting for emergency assistance. 6
• Healthcare providers may administer glucagon intravenously under medical supervision. 6

Post-Glucagon Care

• Call for emergency assistance immediately after administering glucagon. 6
• When the patient responds to treatment and is able to swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence of hypoglycemia. 6
• Staff should have glucagon for intramuscular injection or glucose for intravenous infusion available to treat severe hypoglycemia without requiring transport to an outside facility. 4

Critical Pitfalls to Avoid

• Never delay treatment while waiting for blood glucose confirmation if hypoglycemia is suspected based on symptoms. 3
• Do not use complex carbohydrates or high-protein foods for initial treatment as they are less effective. 3
• Failing to provide a meal after glucose normalizes can lead to recurrent hypoglycemia. 3
• If taking α-glucosidase inhibitors, use only glucose tablets or monosaccharides, as these drugs prevent digestion of complex carbohydrates and will delay treatment effectiveness. 2

Post-Event Management and Prevention

Immediate Follow-Up

• Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia requires reevaluation of the diabetes management plan. 4
• In cases of unexplained or recurrent severe hypoglycemia, consider admission to a medical unit for observation and stabilization. 4

Patient and Caregiver Education

• All patients at risk for clinically significant hypoglycemia should be prescribed glucagon, including those on insulin or sulfonylurea therapy. 2, 3
• Caregivers and family members should be instructed on glucagon administration, including where it is kept and when and how to administer it. 1, 2
• Patients must have immediate access to glucose tablets or other glucose-containing foods at all times. 4, 2
• Educate patients about high-risk situations including fasting for tests or procedures, delayed or skipped meals, intense exercise, alcohol consumption, sleep, and declining renal function. 1, 3

Long-Term Prevention Strategies

• For patients with hypoglycemia unawareness or recurrent severe episodes, raise glycemic targets for at least several weeks to reverse hypoglycemia unawareness and reduce risk of future episodes. 2, 3
• Review and adjust medication regimens, especially insulin dosing and sulfonylureas. 2
• Consider continuous glucose monitoring (CGM) for all individuals with increased risk for hypoglycemia, impaired hypoglycemia awareness, or history of severe hypoglycemia. 7

Institutional and Correctional Settings

• Train all staff who supervise patients at risk for hypoglycemia in recognition, treatment, and appropriate referral. 4
• Implement protocols requiring notification of physicians for blood glucose results outside specified ranges (e.g., <50 mg/dL). 4, 2
• Ensure immediate access to glucose tablets or equivalent for both patients and staff. 4
• Train appropriate staff to administer glucagon. 4
• Identify patients at greater risk for hypoglycemia and consider housing them closer to medical units to minimize treatment delays. 4