What is the management for an insulin regular reaction, specifically hypoglycemia?

Management of Insulin Regular Reaction (Hypoglycemia)

Immediately administer 15-20 grams of oral glucose for any conscious patient with blood glucose ≤70 mg/dL, recheck in 15 minutes, and repeat treatment if hypoglycemia persists; for unconscious patients or those unable to swallow, give 1 mg intramuscular/subcutaneous glucagon immediately or 10-20 grams of IV 50% dextrose. 1, 2, 3

Immediate Recognition and Treatment Threshold

• Treat all blood glucose levels ≤70 mg/dL promptly, even in the absence of symptoms, as this threshold predicts subsequent severe hypoglycemia and requires immediate intervention 1, 3
• For blood glucose between 0.7-1 g/L (3.8-5.5 mmol/L or approximately 60-100 mg/dL), administer glucose if the patient reports hypoglycemic symptoms 1
• Never delay treatment while waiting for blood glucose confirmation if hypoglycemia is suspected based on clinical presentation 2, 3

Treatment Protocol for Conscious Patients

First-Line Oral Treatment

• Administer 15-20 grams of glucose orally as the preferred initial treatment 1, 2, 3
• Pure glucose tablets or glucose solution are most effective because the glycemic response correlates better with glucose content than total carbohydrate content 3
• Any carbohydrate-containing food with glucose can be used if glucose tablets are unavailable, though orange juice and glucose gel are less effective than glucose tablets 3
• Avoid adding fat to carbohydrate treatment as it slows and prolongs the acute glycemic response 3
• Do not use protein to treat hypoglycemia as it may increase insulin secretion 3

Monitoring and Repeat Dosing

• Recheck blood glucose 15 minutes after carbohydrate ingestion 1, 2, 3
• Initial response should occur within 10-20 minutes 3
• If blood glucose remains below 70 mg/dL, repeat treatment with another 15-20 grams of carbohydrate 1, 2, 3
• Evaluate blood glucose again 60 minutes after initial treatment 3
• Once the patient responds and can swallow safely, give oral carbohydrates followed by long-acting carbohydrates to restore liver glycogen and prevent recurrence 4, 5

Treatment Protocol for Unconscious or Severely Impaired Patients

Glucagon Administration (No IV Access)

• Administer 1 mg (1 mL) intramuscular or subcutaneous glucagon immediately into the upper arm, thigh, or buttocks for adults and children weighing >25 kg or ≥6 years 2, 4
• For children weighing <25 kg or <6 years, administer 0.5 mg (0.5 mL) 4
• Family members and caregivers can and should administer glucagon—this is not limited to healthcare professionals 2
• Never attempt oral glucose in an unconscious patient due to aspiration risk 2
• If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 4
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration 3

Intravenous Dextrose (IV Access Available)

• Administer 10-20 grams of IV 50% dextrose immediately, titrated based on the initial hypoglycemic value 2
• A 25-gram IV dextrose dose produces blood glucose increases of approximately 162 mg/dL at 5 minutes and 63.5 mg/dL at 15 minutes 2
• Recheck blood glucose after 15 minutes and repeat dextrose if blood glucose remains below 70 mg/dL 2
• Continue monitoring every 15 minutes until blood glucose stabilizes above 70 mg/dL 2
• Avoid overcorrection that causes iatrogenic hyperglycemia 2

Critical Actions During Hypoglycemia

• Stop any insulin infusion immediately if the patient is receiving IV insulin 2
• Call for emergency assistance immediately after administering glucagon 4
• Document blood glucose before treatment if possible, but never delay treatment 2, 3
• After apparent clinical recovery, continued observation and additional carbohydrate intake are necessary to avoid recurrence, as hypoglycemia may persist longer than expected, particularly with regular insulin overdose 5, 6

Post-Event Management and Prevention

Immediate Review

• Any episode of severe hypoglycemia or recurrent mild-to-moderate hypoglycemia requires reevaluation of the diabetes management plan 3
• Review and adjust insulin dosing, meal patterns, or exercise as needed 5
• In cases of unexplained or recurrent severe hypoglycemia, consider hospital admission for observation and stabilization 3

Patient and Caregiver Education

• Instruct caregivers and family members on glucagon administration, including where it is kept and when and how to administer it 3
• Educate patients on recognizing early hypoglycemia symptoms 2
• Prescribe glucagon for home use and train family members on administration 2
• Advise patients to always carry at least 15 grams of fast-acting glucose (glucose tablets or glucose-containing foods) at all times 1, 2, 3
• Recommend medical identification (bracelet or wallet card) indicating diabetes and insulin use 1

High-Risk Situations Requiring Extra Vigilance

• Patients should understand situations that increase hypoglycemia risk: fasting for tests or procedures, delayed or skipped meals, intense exercise, alcohol consumption, sleep, and declining renal function 3
• History of recurrent severe hypoglycemia or hypoglycemia unawareness requires intensive monitoring 2
• Concurrent illness, sepsis, hepatic failure, or renal failure increases risk 2

Common Pitfalls and Caveats

• Regular insulin has a longer duration of action than rapid-acting analogs, increasing the risk of prolonged or recurrent hypoglycemia 1
• In insulin overdose cases, prolonged aggressive IV glucose infusion may be required, as hypoglycemia can persist much longer than predicted from conventional duration of action 6
• Hypoglycemia unawareness (reduced ability to recognize symptoms) can develop with recurrent hypoglycemia; a 2-3 week period of scrupulous avoidance of hypoglycemia can reverse this condition 7
• For patients on 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 3
• Excess insulin relative to food intake or energy expenditure is the most common cause of hypoglycemia in insulin-treated patients 5, 7