What is the best treatment for a patient experiencing hypoglycemia (low blood glucose)?

Treatment of Hypoglycemia

For conscious patients with low blood glucose, administer 15-20 grams of pure glucose (preferably glucose tablets) immediately, and recheck blood glucose after 15 minutes; for severe hypoglycemia with altered mental status or unconsciousness, administer 1 mg glucagon intramuscularly (or 0.5 mg for children <25 kg) and call emergency services. 1, 2

Immediate Treatment for Conscious Patients (Mild-to-Moderate Hypoglycemia)

First-Line Treatment

• Administer 15-20 grams of fast-acting carbohydrate when blood glucose is ≤70 mg/dL (3.9 mmol/L). 1, 2
• Pure glucose is the preferred treatment because it raises blood glucose more effectively than equivalent amounts of other carbohydrates. 1, 3
• Glucose tablets or glucose solution are the most effective options and should be used when available. 2
• Any carbohydrate-containing food with glucose can serve as an alternative if glucose tablets are unavailable (juice, regular soda, candy). 1, 2

Critical Pitfall to Avoid

• Do NOT use carbohydrate sources high in protein (such as milk, peanut butter crackers, or protein bars) as they may increase insulin secretion without adequately raising glucose levels. 1, 3
• Avoid foods with added fat (chocolate, cookies) as they retard and prolong the acute glycemic response, delaying recovery. 1

Follow-Up Protocol

• Recheck blood glucose after 15 minutes. 1, 2
• If hypoglycemia persists (<70 mg/dL), repeat treatment with another 15-20 grams of carbohydrate. 1, 2
• Once blood glucose normalizes, the patient must consume a meal or snack to prevent recurrent hypoglycemia, as ongoing insulin activity can cause relapse. 1, 3

Special Consideration for Automated Insulin Delivery

• 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. 3

Treatment for Severe Hypoglycemia (Unconscious, Seizing, or Unable to Swallow)

Immediate Actions

• Call emergency services immediately. 2
• Administer glucagon 1 mg intramuscularly for adults and children weighing >25 kg or ≥6 years of age. 2, 4
• Administer glucagon 0.5 mg intramuscularly for children weighing <25 kg or <6 years of age. 4
• Inject into the upper arm, thigh, or buttocks. 2, 4

Glucagon Formulations

• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration, reduced risk of needle-stick injury, and faster correction of hypoglycemia. 2, 3
• Traditional glucagon injection powder requires reconstitution prior to injection, which can delay treatment. 1
• Glucagon administration is not limited to healthcare professionals—family members, caregivers, and school personnel should be trained to administer it. 1, 2

If No Response After 15 Minutes

• An additional dose of glucagon (1 mg for adults/children >25 kg, or 0.5 mg for children <25 kg) may be administered using a new kit while waiting for emergency assistance. 4

Intravenous Dextrose (Healthcare Setting)

• Administer 10-20 grams of intravenous 50% dextrose solution if IV access is available, titrated based on the initial hypoglycemic value. 2
• Stop any insulin infusion immediately if present. 2
• Recheck blood glucose after 15 minutes and repeat dextrose administration if blood glucose remains <70 mg/dL. 2

Post-Recovery Care

• When the patient regains consciousness and can swallow, give oral carbohydrates to restore liver glycogen and prevent recurrence. 4

Critical Prescribing Requirement

All patients at risk of severe hypoglycemia must be prescribed glucagon so it is available when needed. 1, 3 This includes:

• All insulin-treated patients
• Patients with a history of severe hypoglycemia
• Patients with hypoglycemia unawareness
• Patients with a pattern of unexplained level 2 hypoglycemia (<54 mg/dL)

Post-Treatment Management and Prevention

Medication Reevaluation

• Any episode of severe hypoglycemia or recurrent episodes of mild-to-moderate hypoglycemia requires reevaluation of the diabetes management plan. 1, 2
• Patients with hypoglycemia unawareness or clinically significant hypoglycemia should raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks, which partially reverses hypoglycemia unawareness (Grade A evidence). 1, 2

Patient Education Essentials

• Patients should always carry a source of sugar (glucose tablets, candy, sugar packets) with them. 1
• Family members and caregivers should be educated about recognizing hypoglycemia symptoms and how to administer treatment. 1
• Patients should wear medical alert identification stating they have diabetes. 1

Situations That Increase Hypoglycemia Risk

• Fasting for laboratory tests or procedures 1
• Delayed meals 1
• Alcohol consumption 1
• Intense or prolonged exercise 1
• During sleep 1

Important Clinical Caveats

When Glucagon May Not Work

• Glucagon is only effective if sufficient hepatic glycogen is present. 4
• Patients in states of starvation, with adrenal insufficiency, or chronic hypoglycemia may not have adequate hepatic glycogen for glucagon to be effective—these patients should be treated with intravenous glucose. 4

Contraindications to Glucagon

• Glucagon is contraindicated in patients with insulinoma as it may stimulate exaggerated insulin release and worsen hypoglycemia. 4
• Glucagon is contraindicated in patients with pheochromocytoma. 4
• Glucagon is contraindicated in patients with known hypersensitivity to glucagon. 4