What is the significance of a patient's, Polizzi Mary Theresa, blood glucose level being 68 mg/dL (hypoglycemia) initially and 72 mg/dL after consuming juice and a popsicle?

From the Guidelines

The patient's blood glucose level is low at 68 mg/dL, which is considered hypoglycemia (blood glucose <70 mg/dL), and the appropriate intervention was provided by giving juice and a popsicle, which are quick sources of simple carbohydrates, as recommended by the 2023 standards of care in diabetes 1. The follow-up fingerstick glucose of 72 mg/dL shows improvement but is still borderline low. According to the guidelines, glucose (approximately 15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), and since the patient's level is still below 80 mg/dL, I recommend providing an additional 15 grams of carbohydrates (such as 4 oz of juice or 3-4 glucose tablets) to help raise the blood glucose level. Some key points to consider in managing hypoglycemia include:

• Level 1 hypoglycemia is defined as a measurable glucose concentration <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L) 1
• Level 2 hypoglycemia (defined as a blood glucose concentration <54 mg/dL [3.0 mmol/L]) is the threshold at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event 1
• The underlying cause of the hypoglycemia should be investigated, including review of medications (particularly insulin or sulfonylureas), recent food intake, and any unusual physical activity, as hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should trigger hypoglycemia avoidance education and reevaluation and adjustment of the treatment plan to decrease hypoglycemia 1. Once the immediate hypoglycemia is resolved, the patient should consume a more substantial snack containing both carbohydrates and protein (like crackers with cheese or peanut butter) to maintain stable blood glucose levels, and ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if impaired or declining cognition is found 1.

From the Research

Hypoglycemia Management

• The patient's blood glucose level was initially 68 mg/dL, which is below the normal range, and after administering juice and a popsicle, the level increased to 72 mg/dL 2.
• Hypoglycemia is defined as a blood glucose level under 70 mg/dL, and symptoms may occur at higher blood glucose levels in individuals with poor glycemic control 2.
• The American Diabetes Association recommends that a management protocol for hypoglycemia should be designed and implemented, along with a clear prevention and treatment plan 2.

Treatment and Prevention

• The use of glucagon to restore plasma glucose after mild hypoglycemia may be impaired in patients on a low-carbohydrate diet 3.
• Optimizing insulin doses and carbohydrate intake, as well as a short warm-up before or after physical activity sessions, may help avoid hypoglycemia 2.
• Continuous glucose monitoring (CGM) should be considered for individuals with increased risk for hypoglycemia, impaired hypoglycemia awareness, frequent nocturnal hypoglycemia, and a history of severe hypoglycemia 2.

Pathogenesis of Hypoglycemia

• In absolute endogenous insulin deficiency, such as in type 1 diabetes and advanced type 2 diabetes, the absence of an increment in glucagon secretion plays a key role in the pathogenesis of iatrogenic hypoglycemia 4.
• The mechanisms that underlie glucose sensing during hypoglycemia involve specialized neurons in the brain and periphery, and the ventromedial hypothalamus appears to play a major role 5.
• Recurrent hypoglycemia can disturb the sensing mechanism, triggering counter-regulatory defense responses at a lower glucose level 5.