What is the next step for a pregnant patient with type 2 diabetes who took Lantus (insulin glargine) this morning before eating and has hypoglycemia, with a glucose level of 55 mg/dL, after consuming juice and crackers twice?

From the Guidelines

The next step for this pregnant patient with type 2 diabetes experiencing persistent hypoglycemia (blood glucose of 55 mg/dL) despite two rounds of juice and crackers is to administer glucagon. She should receive either 1 mg of injectable glucagon intramuscularly or intravenously, or use a glucagon nasal spray. After administration, continue to monitor her blood glucose every 15 minutes until it rises above 70 mg/dL and remains stable. Once stabilized, she should eat a more substantial meal containing complex carbohydrates and protein to maintain blood glucose levels. This situation requires urgent attention despite the patient feeling subjectively well, as prolonged hypoglycemia poses serious risks to both mother and fetus, as noted in the most recent guidelines 1. The persistent low blood glucose likely results from excess circulating insulin from her morning Lantus dose, which has a long duration of action (up to 24 hours) 1. Following resolution, her diabetes management plan should be reviewed with her healthcare provider, as her insulin dosage likely needs adjustment to prevent future hypoglycemic episodes during pregnancy, when insulin requirements can fluctuate significantly 1. Key considerations include the patient's increased risk of hypoglycemia in pregnancy, altered counterregulatory response, and the importance of education on hypoglycemia prevention, recognition, and treatment 1. Given the potential for severe complications, including diabetic ketoacidosis, especially in the context of pregnancy, careful management and monitoring are crucial 1.

From the FDA Drug Label

Step 11: If the person does not awaken within 15 minutes, give another dose of Glucagon and inform a doctor or emergency services right away

The patient's sugar level is still 55 after receiving juice and crackers twice. Another dose of Glucagon should be considered if the patient is unconscious or not responding, but since the patient feels OK, the next step would be to continue monitoring the patient's blood sugar level and provide another source of glucose. However, since the patient has already received juice and crackers twice, it would be best to seek medical attention to rule out any other underlying issues. Inform a doctor or emergency services right away.

From the Research

Hypoglycemia Treatment

The patient's blood sugar level is 55, which is considered hypoglycemic. Despite consuming juice and crackers twice, her blood sugar level remains the same.

• The patient has type 2 diabetes and is taking Lantis, which may be contributing to her hypoglycemia.
• According to the studies 2, 3, 4, 5, 6, glucagon is an effective treatment for hypoglycemia, especially in emergency situations.

Treatment Options

• Intramuscular glucagon has been shown to be effective in treating hypoglycemia, with a slower but more predictable recovery compared to intravenous dextrose 3, 4, 5.
• Intranasal glucagon is also a viable option, with studies indicating it is equally effective as injectable glucagon in conscious patients with type 1 diabetes 6.
• The patient's condition and response to treatment should be closely monitored, as some studies suggest that glucagon may have a slower onset of action compared to intravenous dextrose 3, 4, 5.

Next Steps

• Consider administering glucagon to the patient, either intramuscularly or intranasally, depending on the availability and the patient's condition.
• Continue to monitor the patient's blood sugar levels and adjust treatment as necessary.
• If the patient's condition does not improve, consider seeking additional medical attention or consulting with a healthcare professional for further guidance.