What treatment is given to a patient on insulin (intramuscular/intravenous medication) to manage hypoglycemia (low blood sugar) in an outpatient setting?

From the Guidelines

For treating hypoglycemia in outpatients on insulin, I recommend prescribing glucagon for emergency use and advising patients to consume 15-20g of fast-acting carbohydrates for mild to moderate hypoglycemia. A standard Canadian prescription for glucagon would be: "Glucagon 1 mg injection kit, dispense 1-2 kits. Inject 1 mg subcutaneously or intramuscularly for severe hypoglycemia when the patient is unable to consume oral glucose. May repeat once after 15 minutes if no response. Refill: 2 times" 1.

Key Points for Treatment:

• For mild to moderate hypoglycemia, patients should follow the "15-15 rule": consume 15g of fast-acting carbohydrate, wait 15 minutes, recheck blood glucose, and repeat if still below 4.0 mmol/L 1.
• Fast-acting carbohydrates can include glucose tablets (4-5 tablets providing 15-20g of glucose), 175 mL of juice or regular soda, or 15 mL (1 tablespoon) of honey.
• After recovery, a small snack containing protein and complex carbohydrates helps maintain stable blood glucose.
• Glucagon works by stimulating the liver to release stored glucose when a patient cannot safely consume oral carbohydrates, making it essential for severe hypoglycemic episodes.

Rationale:

The most recent guidelines from 2022 emphasize the importance of treating hypoglycemia with fast-acting carbohydrates at a blood glucose level of 70 mg/dL (3.9 mmol/L) or less 1. Glucagon is recommended for emergency use in severe hypoglycemia when the patient is unable to consume oral glucose 1. By following these guidelines, patients with diabetes on insulin can effectively manage hypoglycemic episodes and reduce the risk of complications.

From the FDA Drug Label

Instruct the patient or caregiver to read the Instructions for Use at the time they receive a prescription for Glucagon for Injection The recommended dosage is 1 mg (1 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously 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.

To treat hypoglycemia in a patient on insulin as an outpatient, glucagon can be administered. The recommended dosage for adults and pediatric patients weighing more than 25 kg is 1 mg (1 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously 2.

• Key administration instructions:
  • Administer glucagon as soon as possible when severe hypoglycemia is recognized
  • Call for emergency assistance immediately after administering the dose
  • Give oral carbohydrates when the patient is able to swallow to restore liver glycogen and prevent recurrence of hypoglycemia A Canadian prescription for glucagon would be:
• Glucagon for injection 1 mg/mL
• Dosage: 1 mg (1 mL) subcutaneously or intramuscularly
• Frequency: as needed for severe hypoglycemia
• Route: subcutaneously or intramuscularly into the upper arm, thigh, or buttocks, or intravenously by a healthcare provider.

From the Research

Treatment for Hypoglycemia in Insulin-Treated Diabetic Patients

• According to 3, hypoglycemia remains a major limiting factor to successful glycaemic management, despite the availability of prevention options such as insulin analogues, continuous glucose monitoring, insulin pumps, and dogs that have been trained to detect hypoglycaemia.
• Education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention, and treatment of hypoglycemia 3.
• For severe hypoglycemia outside the hospital environment, the first choice of therapy is glucagon injection, an undertaught and underused remedy 4.

Glucagon Therapy for Hypoglycemia

• Glucagon is used as an emergency drug in hypoglycemia, mainly when the patient is unconscious 5.
• The effectiveness of glucagon alone and in comparison with dextrose, as well as the effectiveness of intranasal glucagon in comparison with injected glucagon, has been evaluated in several studies 5.
• Glucagon knowledge was better in patients that attended at least one diabetes lecture, and the main significant positive predictor of glucagon knowledge was history of severe hypoglycemia 4.

First Aid Glucose Administration Routes for Symptomatic Hypoglycemia

• The best enteral route for glucose administration for suspected hypoglycemia in a first aid situation is unknown 6.
• Glucose administration by the sublingual route resulted in a higher blood glucose concentration after 20 minutes compared with the oral route in children with hypoglycemia and symptoms of concomitant malaria or respiratory tract infection 6.
• Oral glucose administration results in a higher blood glucose concentration after 20 minutes when compared with buccal administration of glucose 6.

Canadian Prescription for Hypoglycemia Treatment

• A common prescription for hypoglycemia treatment in Canada is glucagon injection, which can be administered via intramuscular or subcutaneous injection.
• The typical dosage for glucagon injection is 1 mg, which can be repeated as needed if the patient does not respond to the initial dose.
• It is essential to note that glucagon injection should only be administered by a trained healthcare professional or caregiver, and the patient should be closely monitored for any adverse reactions.