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

Reversal of Hypoglycemia

Immediate Treatment for Conscious Patients

For any person with hypoglycemia (blood glucose ≤70 mg/dL) who is conscious and able to swallow, immediately administer 15-20 grams of fast-acting carbohydrates, with pure glucose tablets being the preferred treatment. 1, 2

The 15-15 Rule

• Administer 15-20 grams of fast-acting carbohydrates as soon as hypoglycemia is recognized (blood glucose ≤70 mg/dL), even if symptoms are minimal 1, 2, 3
• Wait exactly 15 minutes, then recheck blood glucose 1, 2
• If blood glucose remains <70 mg/dL after 15 minutes, repeat with another 15-20 grams of carbohydrates 1, 2
• Once blood glucose normalizes, provide a meal or snack containing carbohydrates to prevent recurrence 2, 4

Preferred Carbohydrate Sources (in order of effectiveness)

Pure glucose tablets are the most effective treatment because the glycemic response correlates better with glucose content than total carbohydrate content. 1, 2

• First choice: Pure glucose tablets (15-20 grams) 1, 2
• Acceptable alternatives when glucose tablets unavailable: 4 ounces fruit juice, 4 ounces regular soda, or hard candy 1, 3
• Avoid: Carbohydrate sources high in protein (may increase insulin secretion without adequately raising glucose) and foods high in fat (may slow the glycemic response) 1, 2, 4

Special Dosing Considerations

• For patients using automated insulin delivery systems, a smaller amount (5-10 grams) of carbohydrates may be appropriate unless hypoglycemia is associated with exercise or significant meal bolus overestimation 2

Treatment for Severe Hypoglycemia (Unconscious or Unable to Swallow)

If the person is unconscious, having seizures, or unable to follow simple commands or swallow safely, call emergency medical services immediately and administer glucagon. 1

Glucagon Administration

• All patients at risk for severe hypoglycemia should be prescribed glucagon (those on insulin or sulfonylurea therapy) 2, 3, 5
• Newer formulations (intranasal and ready-to-inject) are strongly preferred due to ease of administration and faster correction compared to traditional injectable glucagon 2, 5, 6

Dosing by Weight (FDA-approved)

Adults and children >25 kg (or age ≥6 years with unknown weight):

• Administer 1 mg (1 mL) subcutaneously, intramuscularly (upper arm, thigh, or buttocks), or intravenously 5
• If no response after 15 minutes, may give additional 1 mg dose using a new kit while waiting for emergency assistance 5

Children <25 kg (or age <6 years with unknown weight):

• Administer 0.5 mg (0.5 mL) subcutaneously, intramuscularly, or intravenously 5
• If no response after 15 minutes, may give additional 0.5 mg dose using a new kit while waiting for emergency assistance 5

Post-Glucagon Care

• Once the patient responds and can swallow, immediately give oral carbohydrates to restore liver glycogen and prevent recurrence 5
• Call emergency medical services even if the patient responds to glucagon 1

Critical Pitfalls to Avoid

• Never delay treatment while waiting for blood glucose confirmation if hypoglycemia is suspected based on symptoms 3
• Do not use complex carbohydrates or high-protein foods for initial treatment (e.g., chocolate, peanut butter crackers) 1, 3
• Do not call EMS prematurely for mild symptomatic hypoglycemia—wait 10-15 minutes after initial treatment before re-treating or calling EMS, unless the patient's status deteriorates 1
• Never administer insulin to someone experiencing hypoglycemia under any circumstances 3
• Ensure glucagon is not expired and caregivers know how to use it before an emergency occurs 2

Understanding Hypoglycemia Severity Levels

The American Diabetes Association classifies hypoglycemia into three levels to guide treatment urgency 1:

• Level 1 (Alert Value): 54-69 mg/dL—treat with 15-20g carbohydrates 1
• Level 2 (Clinically Significant): <54 mg/dL—neuroglycopenic symptoms begin, requires urgent treatment 1
• Level 3 (Severe): Any glucose level with altered mental/physical status requiring assistance from another person—requires glucagon 1