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

From the Guidelines

Hypoglycemia should be treated immediately with 15-20 grams of fast-acting carbohydrates, and if severe, emergency glucagon administration is necessary, as recommended by the most recent guidelines from 2023 1.

Definition and Classification

Hypoglycemia is a condition characterized by abnormally low blood glucose levels, typically below 70 mg/dL (3.9 mmol/L), and is classified into three levels: level 1 (blood glucose <70 mg/dL but ≥54 mg/dL), level 2 (blood glucose <54 mg/dL), and level 3 (severe hypoglycemia requiring assistance from another person for recovery) 1.

Treatment and Prevention

Immediate treatment involves consuming 15-20 grams of fast-acting carbohydrates such as glucose tablets, fruit juice, regular soda, or honey, followed by rechecking blood glucose after 15 minutes and repeating treatment if levels remain low 1. For severe hypoglycemia with unconsciousness or inability to swallow safely, emergency glucagon administration is necessary, available as injectable glucagon, nasal glucagon, or pre-filled autoinjectors 1.

Causes and Risk Factors

Common causes of hypoglycemia include excess insulin or oral diabetes medications, delayed/skipped meals, unplanned exercise, alcohol consumption, and certain medications 1. Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter, and glucagon should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia 1.

Management and Education

Hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should trigger hypoglycemia avoidance education and reevaluation of the treatment plan to decrease hypoglycemia 1. Insulin-treated patients with hypoglycemia unawareness, one level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks 1. Some key points to consider in the management of hypoglycemia include:

• Regular blood glucose monitoring
• Consistent meal timing
• Adjusting medication doses before exercise
• Carrying fast-acting carbohydrates
• Wearing medical identification
• Ongoing assessment of cognitive function with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if impaired or declining cognition is found 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION 2. 1 Important Administration Instructions for Using the Glucagon Emergency Kit for Low Blood Sugar to Treat Severe Hypoglycemia

Glucagon for Injection is for subcutaneous, intramuscular, or intravenous injection. Administer intravenously ONLY under medical supervision. Instruct patients and their caregivers on the signs and symptoms of severe hypoglycemia Because severe hypoglycemia requires the help of others to recover, instruct the patient to inform those around them about Glucagon for Injection and its Instructions for Use. Administer Glucagon for Injection as soon as possible when severe hypoglycemia is recognized Instruct the patient or caregiver to read the Instructions for Use at the time they receive a prescription for Glucagon for Injection Emphasize the following instructions to the patient or caregiver: Using the supplied prefilled syringe, carefully insert the needle through the rubber stopper of the vial containing Glucagon for Injection powder and inject all the liquid from the syringe into the vial. Shake the vial gently until the powder is completely dissolved and no particles remain in the fluid The reconstituted solution should be clear and colorless. Inspect visually for particulate matter and discoloration. If the resulting solution is cloudy or contains particulate matter do not use. The reconstituted solution is 1 mg per mL glucagon. Immediately after reconstitution, inject the solution subcutaneously or intramuscularly in the upper arm, thigh, or buttocks In addition, healthcare providers may administer intravenously. Call for emergency assistance immediately after administering the dose. When 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. Discard any unused portion.

The recommended treatment for hypoglycemia is:

• 1 mg (1 mL) of Glucagon for Injection injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously for adults and pediatric patients weighing more than 25 kg or for pediatric patients with unknown weight 6 years and older.
• 0.5 mg (0.5 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously for pediatric patients weighing less than 25 kg or for pediatric patients with unknown weight less than 6 years of age. If there has been no response after 15 minutes, an additional dose of Glucagon for Injection may be administered using a new kit while waiting for emergency assistance 2. Glucagon for Injection is indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes 2.

From the Research

Definition and Prevalence of Hypoglycaemia

• Hypoglycaemia is defined as a blood glucose level under 70 mg/dL (3.9 mmol/L) 3
• It is a common complication in patients with diabetes, mainly in those treated with insulin, sulfonylurea, or glinide 4
• Hypoglycaemia constitutes a major limiting factor in achieving glycaemic control among people with diabetes 3

Risk Factors and Prevention

• Impairments in counterregulatory responses and hypoglycemia unawareness constitute the main risk factors for severe hypoglycemia 4
• Increased hypoglycaemia risk is observed with the use of insulin and/or sulphonylureas 3
• Patient education regarding risk factors, warning signs, and treatment of hypoglycemia at an early stage is crucial for prevention 4
• Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycaemia, impaired hypoglycaemia awareness, frequent nocturnal hypoglycaemia and with history of severe hypoglycaemia 3

Treatment and Management

• The American Diabetes Association Standards of Medical Care recommends that a management protocol for hypoglycaemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan 3
• Treatment guidelines for hypoglycaemia recommend 15-20 g of oral glucose or sucrose, repeated after 10-15 min for treatment of the responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for treatment of the unresponsive adult 5
• Glucagon can be used to treat and prevent hypoglycaemia in type 1 diabetes, and new formulations are being developed to make it more practical for use 6
• Education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention and treatment 7

Special Considerations

• Vulnerable patients with T2D at dual risk of severe hypoglycaemia and cardiovascular outcomes show features of "frailty" and may be better treated by the use of GLP-1 receptor agonists or SGLT2 inhibitors rather than insulin 3
• Several therapeutic considerations are important to reduce hypoglycaemia risk during pregnancy, including administration of rapid-acting insulin analogues rather than human insulin, pre-conception initiation of insulin analogues, and immediate postpartum insulin dose reduction 3