What are the symptoms and treatment of hypoglycemia (low blood sugar) in diabetic patients?

Symptoms and Treatment of Hypoglycemia in Diabetic Patients

Symptoms of Hypoglycemia

Hypoglycemia presents with autonomic and neuroglycopenic symptoms that occur as blood glucose falls below 70 mg/dL (3.9 mmol/L), though symptoms may appear at higher levels in patients with chronically poor glycemic control. 1, 2

Autonomic (Adrenergic) Symptoms

• Shakiness is a cardinal symptom of hypoglycemia 1, 3
• Tachycardia (rapid heartbeat) occurs as a counterregulatory response 1, 3
• Palpitations are commonly reported, particularly in morning episodes 3
• Hunger develops as the body signals need for glucose 1
• Irritability manifests early in hypoglycemic episodes 1, 3

Neuroglycopenic Symptoms (Brain Glucose Deprivation)

• Confusion develops as brain glucose supply becomes inadequate 1, 3
• Dizziness is frequently reported, especially upon waking 3
• Altered mental status progresses with worsening hypoglycemia 4
• Loss of consciousness occurs in severe (level 3) hypoglycemia 1, 4
• Seizures represent severe neuroglycopenia 4
• Coma can result from untreated severe hypoglycemia 1

Classification by Severity

• Level 1 hypoglycemia: Glucose <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L) - clinically important threshold requiring action 1
• Level 2 hypoglycemia: Glucose <54 mg/dL (3.0 mmol/L) - threshold where neuroglycopenic symptoms begin and immediate action is required 1
• Level 3 hypoglycemia: Severe event with altered mental/physical status requiring assistance from another person for recovery 1

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Treatment of Hypoglycemia

For Conscious Patients (Level 1 and 2)

Administer 15-20 grams of fast-acting carbohydrates immediately when blood glucose is ≤70 mg/dL, with pure glucose being the preferred treatment. 1, 5

The "15-15 Rule"

• Give 15-20 grams of glucose (glucose tablets preferred) or any carbohydrate containing glucose 1, 5
• Recheck blood glucose after 15 minutes using self-monitoring or continuous glucose monitoring 1, 5
• Repeat treatment if glucose remains <70 mg/dL after 15 minutes 1, 5
• Once normalized, consume a meal or snack to prevent recurrence 1, 5

Carbohydrate Source Selection

• Pure glucose is preferred as it raises blood glucose more effectively than equivalent amounts of other carbohydrates 5
• Any glucose-containing carbohydrate works (regular soft drink, fruit juice, glucose tablets), though response correlates better with glucose content than total carbohydrate 5, 4
• Avoid protein-rich carbohydrates as they may increase insulin secretion without adequately raising glucose 5

Special Consideration for Automated Insulin Delivery

• Use smaller amounts (5-10 grams) of carbohydrates for patients on automated insulin delivery systems, unless hypoglycemia is associated with exercise or significant meal bolus overestimation 5

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For Severe Hypoglycemia (Level 3)

For unconscious patients or those unable to swallow, immediately administer glucagon 1 mg intramuscularly or subcutaneously, or 10-20 grams of intravenous 50% dextrose if IV access is available. 4, 6

Glucagon Administration (No IV Access)

• Dose for adults and children >25 kg or ≥6 years: 1 mg (1 mL) injected subcutaneously or intramuscularly into upper arm, thigh, or buttocks 6
• Dose for children <25 kg or <6 years: 0.5 mg (0.5 mL) injected subcutaneously or intramuscularly 6
• Non-healthcare professionals can administer - family members, caregivers, school personnel should be trained 1, 4, 6
• Newer formulations preferred (intranasal and ready-to-inject) due to ease of administration and faster correction 5
• If no response after 15 minutes, administer additional dose using new kit while waiting for emergency assistance 6

IV Dextrose Administration (Healthcare Setting)

• Administer 10-20 grams of IV 50% dextrose immediately, titrated based on initial hypoglycemic value 4
• Stop any insulin infusion if present 4
• Recheck glucose after 15 minutes and repeat dosing if <70 mg/dL 4
• Continue monitoring every 15 minutes until glucose stabilizes above 70 mg/dL 4
• Avoid overcorrection causing iatrogenic hyperglycemia 4

Critical Safety Points

• Never attempt oral glucose in unconscious patients - creates aspiration risk and is absolutely contraindicated 4
• Do not use buccal glucose as first-line - less effective than swallowed glucose in conscious patients and inappropriate for unconscious patients 4
• Call emergency services immediately after administering glucagon 6
• Once patient can swallow, give oral carbohydrates followed by long-acting carbohydrates to prevent recurrence 4, 6

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Prevention Strategies

Patient Education and Monitoring

• Assess for hypoglycemia at every encounter - ask about both symptomatic and asymptomatic episodes 1
• Educate on high-risk situations: fasting for tests, delayed meals, during/after exercise, and during sleep 1, 3
• Consider continuous glucose monitoring (CGM) for patients with recurrent hypoglycemia, hypoglycemia unawareness, or frequent nocturnal episodes 1, 3
• Keep rapid-acting carbohydrates readily available at all times, including in vehicles 1, 3

Medication Adjustments

• For hypoglycemia unawareness or level 2 episodes: Raise glycemic targets to strictly avoid hypoglycemia for several weeks to partially reverse unawareness 1
• Reevaluate treatment regimen after any episode of level 3 hypoglycemia or development of hypoglycemia unawareness 1

Glucagon Prescription

• Prescribe glucagon for all patients at increased risk of clinically significant hypoglycemia (glucose <54 mg/dL) 1, 5
• Train family members and caregivers on where glucagon is stored and how to administer it 1
• Ensure glucagon is not expired and properly stored; replace when expired 5

High-Risk Populations Requiring Intensive Monitoring

• History of recurrent severe hypoglycemia 4
• Concurrent illness, sepsis, hepatic or renal failure 1, 4
• African Americans are at substantially increased risk 1
• Adults over 60 years of age show high burden of hypoglycemia 1
• Patients with cognitive dysfunction 1