What is the management of hypoglycemia?

Management of Hypoglycemia

Immediate Treatment for Conscious Patients

For any patient with blood glucose ≤70 mg/dL who is conscious and able to swallow, immediately administer 15-20 grams of oral glucose, with pure glucose tablets or solution being the preferred form. 1, 2

Treatment Protocol (The "15-15 Rule")

• Give 15-20 grams of fast-acting carbohydrate immediately when hypoglycemia is recognized 1, 2
• Recheck blood glucose after 15 minutes 1, 2
• If hypoglycemia persists (<70 mg/dL), repeat treatment with another 15-20 grams of carbohydrate 1, 2
• Evaluate blood glucose again 60 minutes after initial treatment to ensure stability 2, 3
• Once blood glucose normalizes, provide a meal or snack to restore liver glycogen and prevent recurrence 1, 2

Preferred Carbohydrate Sources

• Glucose tablets or glucose solution are most effective because the glycemic response correlates better with glucose content than total carbohydrate content 3
• Alternative options include fruit juice, sports drinks, regular soda, or hard candy 1
• Orange juice and glucose gel are less effective at quickly alleviating symptoms compared to glucose tablets 3

Critical Special Consideration for α-Glucosidase Inhibitor Users

• If the patient takes acarbose, miglitol, or voglibose, use ONLY glucose tablets or monosaccharides 1, 2
• These medications prevent digestion of complex carbohydrates, which will delay treatment effectiveness and worsen hypoglycemia 1, 2

Modified Dosing for Automated Insulin Delivery Systems

• 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 3

Immediate Treatment for Unconscious or Severely Altered Patients

Never attempt oral glucose in unconscious patients due to aspiration risk—this is a critical safety pitfall. 2

Glucagon Administration (No IV Access Available)

• Administer glucagon 1 mg (1 mL) subcutaneously or intramuscularly for adults and children weighing >25 kg or ≥6 years 4
• For children weighing <25 kg or <6 years, give 0.5 mg (0.5 mL) subcutaneously or intramuscularly 4
• Inject into the upper arm, thigh, or buttocks 4
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration compared to traditional reconstitution kits 3
• If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 4
• Recovery of consciousness after glucagon is slower than after IV dextrose (6.5 vs. 4.0 minutes on average), though both are effective 5

IV Dextrose Administration (IV Access Available)

• Administer 10-20 grams of hypertonic (50%) dextrose solution intravenously, titrated based on initial glucose value 2
• IV dextrose produces faster recovery of consciousness compared to glucagon (4.0 vs. 6.5 minutes) 5
• Critical pitfall: Avoid overcorrection causing iatrogenic hyperglycemia—titrate dextrose carefully rather than giving excessive amounts 2

Post-Treatment Protocol for Severe Hypoglycemia

• Call for emergency assistance immediately after administering glucagon or IV dextrose 4
• When the patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence 4, 6
• After apparent clinical recovery, continued observation and additional carbohydrate intake may be necessary to avoid reoccurrence 6

Management of Recurrent or Persistent Hypoglycemia

Any episode of severe hypoglycemia or recurrent mild-to-moderate episodes requires immediate reevaluation of the entire diabetes management plan. 3

Immediate Actions

• Immediately discontinue any insulin infusion if present 2
• Review and adjust all glucose-lowering medications, particularly insulin dosing and sulfonylurea use 2
• Document blood glucose before treatment whenever possible, though treatment should never be delayed while waiting for confirmation 3

Hypoglycemia Unawareness Protocol

• For patients with hypoglycemia unawareness or recurrent severe episodes, raise glycemic targets for at least several weeks to strictly avoid further hypoglycemia 1, 2
• This approach partially reverses hypoglycemia unawareness and reduces risk of future episodes by shifting glycemic thresholds back to normal 1, 2
• The mechanism involves breaking the vicious cycle where recent hypoglycemia causes both defective glucose counterregulation and further hypoglycemia unawareness 7
• A 2-3 week period of scrupulous avoidance of hypoglycemia is advisable for patients with hypoglycemia unawareness 7

Prevention Strategies

Patient and Caregiver Education

• All patients at risk for severe hypoglycemia must have glucagon prescribed, and caregivers must be instructed on administration 1, 3
• Educate on where glucagon is kept, when to use it, and how to administer it 3
• Patients should inform those around them about their glucagon kit and its location 4

High-Risk Situations Requiring Extra Vigilance

• Fasting for tests or procedures 1, 2
• Delayed or skipped meals 1, 2
• Intense exercise without dose adjustment 1
• Alcohol consumption (advise consuming only with food) 1
• Sleep 1, 2
• Declining renal function 1, 2

Medication-Related Risk Factors

• Insulin, sulfonylureas, and insulin secretagogues carry the highest hypoglycemia risk, with sulfonylureas having the highest risk among oral agents 1
• Newer anti-diabetic drugs (GLP-1 receptor agonists, SGLT2 inhibitors) have lower hypoglycemia risk 8
• Consider switching high-risk patients from insulin or sulfonylureas to agents with lower hypoglycemia risk 1, 8

Practical Prevention Measures

• Always carry fast-acting glucose sources (glucose tablets, candy, or juice) 1
• Maintain consistent meal timing when on premixed or fixed insulin plans 1
• Adjust insulin doses before exercise performed within 1-2 hours of mealtime insulin 1
• Implement continuous glucose monitoring (CGM) for patients with increased hypoglycemia risk, impaired awareness, frequent nocturnal hypoglycemia, or history of severe episodes 1, 8
• Wear medical alert identification stating diabetes diagnosis 1

Hospital and Institutional Management

Glycemic Targets

• For critically ill (ICU) patients, target blood glucose 140-180 mg/dL 2
• For non-critically ill patients, initiate treatment at threshold ≥180 mg/dL confirmed on two occasions within 24 hours 2
• More stringent targets of 110-140 mg/dL may be appropriate for selected patients (e.g., post-surgical) only if achievable without significant hypoglycemia 2

Institutional Protocols

• Train all staff who supervise at-risk patients in recognition, treatment, and appropriate referral 3
• Implement protocols requiring notification of physicians for blood glucose results outside specified ranges 1, 3
• Ensure immediate access to glucose tablets or equivalent for both patients and staff 3
• Train appropriate staff to administer glucagon 3
• Identify patients at greater risk and consider housing them closer to medical units to minimize treatment delays 3

Pediatric Considerations

• Children ≥42 weeks adjusted gestational age to 18 years with persistent hyperglycemia ≥180 mg/dL should be treated, but protocols must demonstrate low hypoglycemia risk 2
• Critical evidence: Intensive glucose control in critically ill children increases severe hypoglycemia 3-5 fold without mortality benefit 2

Critical Pitfalls to Avoid

• Failing to stop insulin infusions—this perpetuates hypoglycemia despite glucose replacement 2
• Delaying treatment while waiting for blood glucose confirmation—treat immediately based on symptoms if testing unavailable 2
• Not adjusting insulin doses after hypoglycemic episodes 2
• Using sliding scale insulin as the sole insulin regimen 1
• Adding protein to treat hypoglycemia, as it may increase insulin secretion 3
• Adding fat to carbohydrate treatment, which may slow and prolong the acute glycemic response 3

High-Risk Patient Characteristics

• Advanced age (>60 years) 1
• African American race 1
• History of hypoglycemia unawareness 1
• Prior severe hypoglycemia episodes 1
• Endogenous insulin deficiency 7
• Lower HbA1c levels or aggressive glycemic goals 7