What is the best approach to manage a patient with hypoglycemia (low blood sugar)?

Management of Hypoglycemia

For conscious patients with blood glucose ≤70 mg/dL, immediately administer 15-20 grams of fast-acting oral glucose, recheck glucose after exactly 15 minutes, and repeat treatment if hypoglycemia persists; for unconscious patients or those unable to swallow, administer glucagon 1 mg subcutaneously or intramuscularly (0.5 mg for children <20 kg). 1, 2

Immediate Recognition and Treatment Thresholds

Define the Emergency

• Level 1 hypoglycemia: Blood glucose <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL—this is your action threshold 1, 3
• Level 2 hypoglycemia: Blood glucose <54 mg/dL (3.0 mmol/L)—neuroglycopenic symptoms begin, requiring immediate treatment 1, 3
• Level 3 (severe) hypoglycemia: Patient requires assistance from another person due to altered mental status, confusion, seizures, or coma 1, 3

Recognize the Symptoms

• Neurogenic symptoms: Shakiness, diaphoresis, palpitations, anxiety, tremor, hunger 1, 3
• Neuroglycopenic symptoms: Confusion, altered mental status, difficulty concentrating, slurred speech, seizures, or coma 1, 3

Acute Treatment Protocol for Conscious Patients

The 15-15 Rule

• Administer 15-20 grams of fast-acting carbohydrate immediately when blood glucose is ≤70 mg/dL 1, 4
• Pure glucose is the preferred treatment—glucose tablets, fruit juice, regular soda, or sports drinks 1, 5
• Recheck blood glucose after exactly 15 minutes 1, 4
• Repeat the 15-20 gram dose if hypoglycemia persists 1, 4, 3

Critical Treatment Principles

• Never use carbohydrates high in fat or protein for initial treatment—fat delays glycemic response and protein may increase insulin response without raising glucose 1
• Avoid complex carbohydrates alone—the acute glycemic response correlates better with glucose content than total carbohydrate content 1, 5
• Once glucose normalizes, provide a meal or snack to restore liver glycogen and prevent recurrence 1, 2

Treatment for Severe Hypoglycemia (Unconscious or Unable to Swallow)

Glucagon Administration

• Adults and children ≥20 kg: Administer 1 mg (1 mL) glucagon subcutaneously or intramuscularly into upper arm, thigh, or buttocks 2
• Children <20 kg: Administer 0.5 mg (0.5 mL) glucagon or 20-30 mcg/kg 2
• Call emergency services immediately after administering glucagon 2
• If no response after 15 minutes, administer a second dose while waiting for emergency assistance 2
• Turn the patient on their side to prevent aspiration if vomiting occurs 2

Glucagon Prescribing Requirements

• All patients at risk for severe hypoglycemia must be prescribed glucagon 4, 5, 2
• Train caregivers, family members, and school personnel on where glucagon is stored and how to administer it 1, 4, 5
• Multiple formulations are now available: traditional injection requiring reconstitution, intranasal glucagon, and ready-to-use subcutaneous injection 1

Intravenous Treatment (Healthcare Settings)

• Administer IV dextrose for unconscious patients with IV access 4, 2
• Healthcare providers may administer glucagon intravenously under medical supervision 2

Post-Acute Management: Preventing Recurrence

Immediate Post-Treatment Actions

• Feed the patient as soon as they can swallow: Provide fast-acting sugar (regular soft drink or fruit juice) followed by long-acting carbohydrates (crackers with cheese or meat sandwich) 2
• Monitor blood glucose every 1-2 hours initially after severe episodes, then every 4 hours once stable 4
• Document the episode and glucose level before treatment whenever possible 3

Medication Regimen Overhaul

• Any episode of severe hypoglycemia triggers mandatory reevaluation of the entire diabetes management plan 1, 4, 3
• Reduce basal insulin doses immediately—75% of hospitalized patients with hypoglycemia did not have their basal insulin adjusted before the next dose 4
• Never use sliding-scale insulin as the sole insulin regimen—this is strongly discouraged 5, 3

Critical Strategy: Raising Glycemic Targets

For Hypoglycemia Unawareness or Recurrent Severe Episodes

• Raise glycemic targets to strictly avoid hypoglycemia for at least 2-3 weeks 1, 4, 6
• This approach partially reverses hypoglycemia unawareness and reduces future severe episode risk 1, 4
• Implement scrupulous hypoglycemia avoidance during this period—no episodes of blood glucose <70 mg/dL 4, 6

Specific Indications for Raising Targets

• Hypoglycemia unawareness (inability to recognize symptoms) 1
• One or more episodes of level 3 hypoglycemia 1
• Pattern of unexplained level 2 hypoglycemia 1

Prevention Strategies

Patient Education Essentials

• Educate on high-risk situations: Fasting for tests/procedures, delayed meals, alcohol consumption, intense exercise, and sleep 1, 5
• Teach patients to always carry a source of sugar—glucose tablets, candy, or juice 1
• Instruct patients to wear medical alert identification stating diabetes diagnosis 1

Medication-Related Prevention

• Coordinate insulin administration with meal timing to minimize risk 5
• Consider switching from sulfonylureas or insulin to agents with lower hypoglycemia risk (GLP-1 receptor agonists or SGLT2 inhibitors) when appropriate 7
• Implement continuous glucose monitoring (CGM) for all patients with increased hypoglycemia risk, impaired awareness, frequent nocturnal hypoglycemia, or history of severe episodes 1, 7

Nutrition-Insulin Mismatch Prevention

• Nutrition-insulin mismatch is the most common preventable cause of hypoglycemia, often from unexpected meal interruption 4
• Ensure basal insulin continues even if enteral/parenteral feedings are interrupted, particularly critical in type 1 diabetes 4
• For patients on tube feedings requiring insulin: Estimate basal needs as 30-50% of total daily insulin dose 4

Common Pitfalls to Avoid

• Never delay treatment while waiting for blood glucose confirmation—treat based on symptoms if meter unavailable 5
• Never fail to adjust insulin doses after a hypoglycemic episode—this perpetuates the cycle of recurrent hypoglycemia 4, 5
• Never use complex carbohydrates or high-protein foods for initial treatment—they delay glucose absorption 1, 5
• Never assume the patient has recovered after initial treatment—ongoing insulin activity or insulin secretagogues may cause recurrent hypoglycemia 1

Institutional and Hospital Protocols

• Train all staff in recognition and treatment of hypoglycemia 4, 5
• Implement standardized hypoglycemia treatment protocols including immediate access to glucose tablets 5, 3
• Establish notification systems for physicians when blood glucose results fall outside specified ranges 5
• Implement "bundled" preventive therapies including proactive surveillance of glycemic outliers—this reduces hypoglycemic events by 56-80% 4

Special Populations

Alcohol Consumption

• Limit alcohol to 1-2 drinks per day—excessive consumption inhibits hepatic glucose release, exacerbating hypoglycemia 1
• Always consume alcohol with food to reduce hypoglycemia risk 5

Pregnancy

• Administer rapid-acting insulin analogues rather than human insulin 7
• Initiate insulin analogues pre-conception 7
• Reduce insulin doses immediately postpartum 7