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

Immediate Treatment of Hypoglycemia

For conscious patients with hypoglycemia, immediately administer 15-20 grams of oral glucose, preferably as glucose tablets or solution, and recheck blood glucose in 15 minutes. 1

Recognition and Initial Assessment

• Hypoglycemia is defined as blood glucose ≤70 mg/dL (≤3.9 mmol/L) and requires prompt treatment. 1, 2
• If blood glucose testing is not immediately available, do not delay treatment—administer therapy based on clinical suspicion. 2, 1
• Clinically significant hypoglycemia occurs when blood glucose falls below 54 mg/dL (<3.0 mmol/L). 2

Treatment Protocol for Conscious Patients

First-Line Treatment:

• Give 15-20 grams of glucose orally as the preferred initial treatment. 1, 2
• Pure glucose (tablets or solution) is most effective because the glycemic response correlates better with glucose content than total carbohydrate content. 1
• Any glucose-containing carbohydrate can be used if glucose tablets are unavailable, but avoid orange juice and glucose gel as they are less effective at quickly alleviating symptoms. 1

Follow-Up Protocol:

• Recheck blood glucose 15 minutes after carbohydrate ingestion. 1, 2
• If hypoglycemia persists (blood glucose still <70 mg/dL), repeat treatment with another 15-20 grams of carbohydrate. 1, 2
• Once blood glucose exceeds 70 mg/dL (3.9 mmol/L) but the next meal is more than one hour away, give starchy or protein-rich foods to prevent recurrence. 2
• Evaluate blood glucose again 60 minutes after initial treatment. 1

Special Considerations:

• For patients using automated insulin delivery systems, a lower dose of 5-10 grams may be appropriate unless hypoglycemia occurs with exercise or after significant insulin overestimation. 1
• Do not add fat to carbohydrate treatment as it slows the glycemic response. 1
• Never use protein to treat hypoglycemia as it may increase insulin secretion. 1

Treatment for Severe Hypoglycemia (Unconscious or Unable to Swallow)

Immediate Glucagon Administration:

• For patients who cannot safely swallow, are seizing, or have altered mental status, administer glucagon immediately—this is a medical emergency. 3, 1
• Never attempt oral glucose in a seizing or unconscious patient due to aspiration risk. 3

Glucagon Dosing:

• Adults and children weighing >25 kg (or ≥6 years): 1 mg (1 mL) subcutaneously or intramuscularly. 4, 2
• Children weighing <25 kg (or <6 years): 0.5 mg (0.5 mL) subcutaneously or intramuscularly. 4, 2
• Inject into the upper arm, thigh, or buttocks. 4, 5

Post-Glucagon Management:

• Glucagon increases blood glucose within 5-15 minutes. 3
• Turn the patient on their side to prevent aspiration, as nausea and vomiting are common side effects. 5
• If no response after 15 minutes, administer a second dose of glucagon and call emergency services immediately. 4, 5
• Once the patient responds and can swallow, give 15-20 grams of oral carbohydrates followed by a meal or protein-containing snack to restore liver glycogen and prevent recurrence. 3, 5
• Check blood glucose every 15 minutes until levels exceed 70 mg/dL. 3

Alternative for Healthcare Settings:

• Intravenous dextrose (20-40 mL of 50% glucose solution) can be administered if IV access is available, with additional glucose if blood glucose remains <54 mg/dL (<3.0 mmol/L). 2

Critical Clinical Pearls

• Newer intranasal and ready-to-inject glucagon preparations are preferred over traditional reconstituted glucagon due to ease of administration. 1
• Any episode of severe hypoglycemia requires reevaluation of the diabetes management plan. 1
• Patients at risk should carry glucose tablets or glucose-containing foods at all times. 1
• Caregivers and family members must be trained on glucagon administration, including where it is stored and how to use it. 1
• Hypoglycemic seizures indicate severe neuroglycopenia requiring immediate treatment, as seizures can deplete brain glycogen stores and exacerbate hippocampal dysfunction. 3