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

Immediate Treatment of Hypoglycemia

For conscious patients with hypoglycemia (blood glucose ≤70 mg/dL), immediately administer 15-20 grams of oral glucose, preferably as glucose tablets or solution, and recheck blood glucose in 15 minutes—if hypoglycemia persists, repeat the same dose. 1

Recognition and Initial Assessment

• Hypoglycemia is defined as blood glucose ≤70 mg/dL and requires prompt treatment 1
• Document blood glucose before treatment when possible, but never delay treatment while waiting for confirmation 1
• Symptoms include autonomic signs (tremor, pallor, palpitations, sweating) and neuroglycopenic symptoms (confusion, headache, altered mental status, potentially progressing to seizures or coma) 2

Treatment Protocol for Conscious Patients

First-Line Treatment

• Administer 15-20 grams of glucose orally as the immediate treatment 1, 3
• Pure glucose is preferred because the glycemic response correlates better with glucose content than total carbohydrate content 1, 3
• Glucose tablets or glucose solution are the most effective options, providing response within 10-20 minutes 1, 4
• Any carbohydrate-containing food with glucose can be used if glucose tablets are unavailable 1

Monitoring and Repeat Treatment

• Recheck blood glucose 15 minutes after carbohydrate ingestion 1, 3
• If hypoglycemia persists after 15 minutes, immediately repeat treatment with another 15-20 grams of carbohydrate 1, 3
• Evaluate blood glucose again 60 minutes after initial treatment, as additional intervention may be necessary 1, 5
• Continue monitoring every 30-60 minutes until stable for at least 2 hours 5

Special Dosing 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

Treatment for Severe Hypoglycemia (Unconscious or Unable to Swallow)

Glucagon Administration

• For patients unable or unwilling to consume carbohydrates orally, glucagon is indicated 1
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration 1, 6, 7

Dosing by Weight and Age

• Adults and children weighing >25 kg or ≥6 years: 1 mg (1 mL) subcutaneously or intramuscularly 1, 8
• Children weighing <25 kg or <6 years: 0.5 mg (0.5 mL) subcutaneously or intramuscularly 1, 8
• If no response after 15 minutes, an additional dose may be administered using a new kit while waiting for emergency assistance 8
• Call for emergency assistance immediately after administering glucagon 8

Post-Glucagon Care

• When the patient responds and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence 8

Intravenous Treatment (Healthcare Settings)

• Administer 10-20 grams of hypertonic (50%) dextrose intravenously for critically ill patients, titrated based on initial hypoglycemic value 5
• For moderate hypoglycemia in hospital settings, 25-50 mL of 50% glucose solution over 2-3 minutes is effective 9
• Start continuous dextrose-containing IV fluids to prevent recurrence in critically ill patients 5

What NOT to Do: Critical Pitfalls

• Do not use protein to treat hypoglycemia—it may increase insulin secretion and worsen the condition 1, 5
• Do not add fat to carbohydrate treatment as it slows and prolongs the glycemic response 1
• Never delay treatment while waiting for laboratory confirmation 5
• Do not assume resolution after one treatment—approximately 30% of hypoglycemic episodes are resistant and require repeated doses 5
• Orange juice and glucose gel are less effective than glucose tablets or solution and should not be first-line choices 1, 4

Resistant Hypoglycemia

• Resistant hypoglycemia (failing to respond to initial 15-20g glucose) occurs in approximately 30% of cases presenting to emergency departments 5
• Most commonly caused by insulin secretagogues (sulfonylureas) due to prolonged duration of action 5
• Other causes include hepatic failure, renal impairment, alcohol consumption, and prolonged fasting 5
• Patients with sulfonylurea-induced hypoglycemia require 24-48 hours of observation and may need continuous dextrose infusion 5

When to Escalate Care

• Any episode of severe hypoglycemia or recurrent episodes of mild-to-moderate hypoglycemia requires reevaluation of the diabetes management plan 1
• Consider admission for unexplained or recurrent severe hypoglycemia, sulfonylurea-induced hypoglycemia, or underlying infection, hepatic failure, or renal failure 1, 5
• ICU admission may be necessary for patients requiring continuous insulin infusion protocols or frequent glucose monitoring 5

Prevention and Education

• Ensure patients at risk have immediate access to glucose tablets or glucose-containing foods at all times 1
• Caregivers and family members should be instructed on glucagon administration, including where it is kept and when and how to administer it 1
• Patients should understand high-risk situations: fasting for procedures, delayed or skipped meals, intense exercise, alcohol consumption, sleep, and declining renal function 1
• Avoid targeting overly tight glucose control; aim to keep blood glucose >70 mg/dL 1