What is the treatment for hypoglycemia (low blood sugar) in a patient using insulin?

Treatment of Hypoglycemia in Insulin-Using Patients

For conscious patients with hypoglycemia (blood glucose ≤70 mg/dL), immediately administer 15-20g of pure glucose orally, recheck blood glucose after 15 minutes, and repeat treatment if hypoglycemia persists. 1, 2

Immediate Treatment Protocol

For Conscious Patients

• Administer 15-20g of glucose as the first-line treatment when blood glucose is ≤70 mg/dL 1, 2, 3
• Pure glucose (glucose tablets or solution) is strongly preferred because the glycemic response correlates better with glucose content than total carbohydrate content 1, 3, 4
• Any carbohydrate containing glucose can be used if pure glucose is unavailable, though it may be less effective 1, 3
• Expect initial response within 10-20 minutes 1, 3
• Recheck blood glucose 15 minutes after treatment and repeat 15-20g glucose if hypoglycemia persists 1, 3
• Recheck again at 60 minutes as additional treatment may be necessary 1, 3

Special Dosing Considerations

• For patients using automated insulin delivery systems: Use only 5-10g carbohydrates (except for exercise-induced hypoglycemia or significant insulin overestimation) 1, 2, 3
• This lower dose prevents overtreatment in the context of automated insulin adjustments 1

For Severe Hypoglycemia (Unconscious or Unable to Swallow)

• Glucagon is the treatment of choice for patients unable or unwilling to consume oral carbohydrates 1, 3, 5
• Dosing for adults and children ≥25 kg or ≥6 years: 1 mg (1 mL) subcutaneously, intramuscularly, or intravenously 5
• Dosing for children <25 kg or <6 years: 0.5 mg (0.5 mL) subcutaneously, intramuscularly, or intravenously 5
• If no response after 15 minutes, repeat the same dose while waiting for emergency assistance 5
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration and do not require reconstitution 1, 3

Post-Treatment Management

Preventing Recurrence

• Once blood glucose normalizes, consume a meal or snack containing complex carbohydrates and protein to prevent recurrence 1, 2, 5
• This step is critical because ongoing insulin activity can lead to recurrent hypoglycemia 1
• After glucagon administration, give oral carbohydrates when the patient is able to swallow to restore liver glycogen 5, 6

Critical Pitfalls to Avoid

What NOT to Do

• Do not use high-protein foods without adequate glucose content to treat hypoglycemia, as protein may increase insulin secretion and worsen the condition 1, 2, 3
• Do not add fat to initial treatment, as it slows and prolongs the glycemic response 1, 3
• Do not fail to recheck blood glucose after initial treatment, as this leads to recurrent hypoglycemia 2
• Do not delay treatment while waiting for blood glucose confirmation if hypoglycemia is suspected based on symptoms 3

Glucagon Prescription and Education

Who Needs Glucagon

• All individuals at increased risk of severe hypoglycemia (blood glucose <54 mg/dL) should be prescribed glucagon 1
• This includes all insulin-treated patients with a history of severe hypoglycemia or hypoglycemia unawareness 1

Caregiver Training

• Family members, caregivers, and close contacts must be instructed on glucagon administration, including where it is stored and when and how to use it 1, 3, 5
• Glucagon administration is not limited to healthcare professionals 1
• Ensure glucagon kits are not expired 1

Long-Term Prevention Strategies

Patient Education Requirements

• Structured diabetes education programs are strongly recommended for all patients at high risk for hypoglycemia 1
• Patients must understand situations that increase hypoglycemia risk: fasting for procedures, delayed or skipped meals, intense exercise, alcohol consumption, and sleep 1, 3
• All at-risk patients should carry fast-acting glucose sources at all times 2, 3

Treatment Regimen Adjustments

• Any episode of severe hypoglycemia or recurrent moderate hypoglycemia requires reevaluation of the diabetes management plan 1, 3
• Patients with hypoglycemia unawareness or unexplained severe hypoglycemia should raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks 1
• This approach can partially reverse hypoglycemia unawareness and reduce future risk 1

Monitoring Considerations

• Consider continuous glucose monitoring (CGM) for patients with recurrent hypoglycemia or hypoglycemia unawareness 2, 7
• Implement consistent meal timing when on fixed insulin regimens 2
• Include protein and/or fat with meals (not during acute treatment) to slow carbohydrate absorption 2

Special Populations at Higher Risk

Vulnerable Groups

• Young children with type 1 diabetes and elderly individuals are particularly vulnerable due to reduced ability to recognize symptoms and communicate needs 1
• Patients with food insecurity, low income, or who are underinsured experience higher rates of severe hypoglycemia 1
• Patients with declining cognitive function require increased vigilance 1