What should I do if my patient has hypoglycemia (low blood glucose)?

From the Guidelines

A blood glucose level of 1.9 mmol/L is a medical emergency that requires immediate treatment with 15-20 grams of fast-acting carbohydrates, such as glucose tablets, fruit juice, or honey, to prevent serious complications, including seizures, loss of consciousness, and brain damage or death, as recommended by the most recent guidelines 1. The patient should be given 15-20 grams of fast-acting carbohydrates immediately, such as:

• 4 glucose tablets
• 6 ounces of fruit juice
• 8 ounces of regular soda
• 1 tablespoon of honey or sugar dissolved in water After administering these carbohydrates, the blood glucose level should be rechecked in 15 minutes. If it remains below 4.0 mmol/L (70 mg/dL), the treatment should be repeated. If the patient is unconscious or unable to swallow safely, glucagon should be administered - either 1 mg intramuscularly/subcutaneously or use intranasal glucagon (3 mg), and emergency services should be called. For healthcare providers, IV dextrose (25-50 mL of D50W) should be considered if IV access is available, as recommended by the American Diabetes Association 1. The rapid administration of glucose is essential to restore normal brain function, as the brain depends on glucose as its primary energy source. Once the immediate crisis is resolved, the cause of the hypoglycemia should be investigated to prevent recurrence, which may include adjusting diabetes medications, addressing missed meals, or evaluating for other medical conditions, as suggested by the guidelines 1. It is also important to note that hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger reevaluation of the treatment regimen, and insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks, to partially reverse hypoglycemia unawareness and reduce risk of future episodes, as recommended by the guidelines 1.

From the FDA Drug Label

Instruct patients and their caregivers on the signs and symptoms of severe hypoglycemia Administer Glucagon for Injection as soon as possible when severe hypoglycemia is recognized The recommended dosage is 1 mg (1 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously If there has been no response after 15 minutes, an additional 1 mg dose (1 mL) of Glucagon for Injection may be administered using a new kit while waiting for emergency assistance.

If the patient has a blood glucose level of 1.9, this indicates severe hypoglycemia. The patient should be administered 1 mg of Glucagon for Injection subcutaneously, intramuscularly, or intravenously as soon as possible.

• Call for emergency assistance immediately after administering the dose.
• If there is no response after 15 minutes, an additional 1 mg dose of Glucagon for Injection may be administered using a new kit while waiting for emergency assistance.
• Once the patient has responded to the treatment and is able to swallow, give oral carbohydrates to restore the liver glycogen and prevent recurrence of hypoglycemia 2.

From the Research

Hypoglycemia Treatment

If a patient has a blood glucose level of 1.9, it is considered a severe case of hypoglycemia. The following steps can be taken:

• Administer intravenous glucagon (1 mg) or intravenous dextrose (25 g) to treat the hypoglycemia, as both have been shown to be effective in treating hypoglycemic coma 3.
• Consider the use of intranasal glucagon as an alternative to injected glucagon, as it has been shown to be similarly effective 4.
• If the patient is conscious, administer oral carbohydrates, such as glucose tablets or juice, to help raise blood glucose levels.

Prevention of Hypoglycemia

To prevent hypoglycemia, the following measures can be taken:

• Educate patients on the risk factors, warning signs, and treatment of hypoglycemia at an early stage 5.
• Set personalized goals for glycemic control and optimize insulin doses and carbohydrate intake 6.
• Consider the use of continuous glucose monitoring (CGM) for patients with increased risk of hypoglycemia, impaired hypoglycemia awareness, or frequent nocturnal hypoglycemia 6.

Blood Glucose Management

In hospitalized patients, blood glucose management is critical to prevent complications and improve patient outcomes. The following can be considered:

• Summarize existing evidence from observational studies, clinical trials, and society guidelines on blood glucose management in the hospitalized setting 7.
• Consider the use of rapid-acting insulin analogues and pre-conception initiation of insulin analogues to reduce hypoglycemia risk during pregnancy 6.