Standing Orders for Outpatient Hypoglycemia Management
Immediate Treatment Protocol for Conscious Patients
All outpatient diabetes patients experiencing hypoglycemia (blood glucose <70 mg/dL) should receive 15-20 grams of glucose immediately, with blood glucose rechecked at 15 minutes and treatment repeated if hypoglycemia persists. 1, 2
The 15-15 Rule (Core Protocol)
- Administer 15-20 grams of fast-acting carbohydrate containing glucose when blood glucose is <70 mg/dL 1, 2
- Acceptable treatment options include:
- Recheck blood glucose after exactly 15 minutes 1, 2
- Repeat 15-20 grams of glucose if blood glucose remains <70 mg/dL 1, 2
- Once blood glucose normalizes, immediately provide a meal or snack containing complex carbohydrates and protein to prevent recurrence 1, 2
Critical Pitfall to Avoid
Do not use protein sources (milk, cheese, peanut butter) as primary hypoglycemia treatment—they do not raise glucose effectively. 3 These should only be added after glucose normalizes to sustain recovery. 1
Standing Orders for Severe Hypoglycemia (Unconscious or Unable to Swallow)
Glucagon 1 mg must be administered immediately via subcutaneous, intramuscular, or intravenous route for any patient who cannot safely receive oral treatment. 3, 4
Glucagon Administration Protocol
- Dose for adults and children ≥20 kg: 1 mg (1 mL) subcutaneous or intramuscular 4
- Dose for children <20 kg: 0.5 mg (0.5 mL) or 20-30 mcg/kg 4
- Inject into upper arm, thigh, or buttocks 4
- Call 911 immediately after administering glucagon 4
- If no response after 15 minutes, repeat the same dose while waiting for emergency services 4
- Once patient responds and can swallow, give oral carbohydrates immediately to restore liver glycogen 4
Alternative for Healthcare Settings with IV Access
- Administer 10-25 grams intravenous dextrose as alternative to glucagon 3
- Follow with oral carbohydrates once patient can swallow 3
Mandatory Glucagon Prescription Requirements
Glucagon must be prescribed for all patients at significant risk of severe hypoglycemia, with caregivers and family members trained on administration. 1, 2
High-Risk Patients Requiring Glucagon
- All insulin-treated patients 1
- Patients with history of severe hypoglycemia 1
- Patients with hypoglycemia unawareness 1, 2
- Older adults with cognitive impairment 2
- Patients on sulfonylureas or meglitinides with prior hypoglycemia 2
Caregiver Education Requirements
- Glucagon administration is not limited to healthcare professionals—family members and caregivers must be trained 1
- Emphasize that newer glucagon formulations (nasal, auto-injector) do not require reconstitution, making emergency use simpler 5
- Patients should wear medical alert identification 1
Treatment Regimen Reevaluation Triggers
Any blood glucose <70 mg/dL, whether symptomatic or asymptomatic, mandates complete reevaluation of the diabetes treatment regimen. 2
Immediate Actions Required
- Hypoglycemia unawareness or severe hypoglycemia episode triggers mandatory regimen review 1, 2
- Raise glycemic targets to strictly avoid hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness 1, 2
- Reduce insulin doses in insulin-treated patients 2
- Consider discontinuing or reducing sulfonylureas and meglitinides 2
- Document all episodes (symptomatic and asymptomatic) and track patterns 2
Breaking the Hypoglycemia Cycle
Several weeks of scrupulous hypoglycemia avoidance can restore counterregulatory responses and awareness in most patients by temporarily accepting higher blood glucose levels. 2 This is not optional—it is a medical necessity to prevent life-threatening severe hypoglycemia. 2
Monitoring Requirements Post-Hypoglycemia
Monitor blood glucose every 1-2 hours after treatment if patient is on insulin infusion or insulin secretagogues, as recurrence risk is high. 2
- Recheck at 15 minutes post-treatment (mandatory) 2
- Recheck again at 60 minutes, as glucose effect may be temporary 2
- Continue frequent monitoring until stable 2
Patient Education and Supplies
All at-risk patients must carry fast-acting glucose at all times and know how to use it. 1, 2
Required Patient Knowledge Before Discharge
- Recognition of hypoglycemia symptoms (though these may be absent in hypoglycemia unawareness) 1
- When to call healthcare provider 1
- Proper glucose monitoring technique 1
- Sick-day management 1
- Proper disposal of diabetes supplies 1
Mandatory Supplies
- Glucose tablets or glucose-containing foods 1
- Glucagon kit for high-risk patients 1
- Blood glucose meter and test strips 1
- Medical alert bracelet or necklace 1
Follow-Up Requirements
Schedule outpatient follow-up within 1 month for all patients experiencing hypoglycemia; within 1-2 weeks if medications were changed or glucose control is suboptimal. 1
- Earlier appointment (1-2 weeks) preferred if treatment regimen changed 1
- Frequent contact may be needed to adjust therapy and avoid recurrent hypoglycemia 1
- Referral to diabetes care and education specialist or endocrinology for recurrent episodes 1
Special Considerations for High-Risk Populations
Older adults face substantially elevated risk due to cognitive impairment, renal insufficiency, and altered counterregulatory responses. 2
- Ongoing cognitive function assessment with increased vigilance for hypoglycemia 1
- Consider continuous glucose monitoring (CGM) to capture asymptomatic episodes 5
- Lower treatment intensity and higher glycemic targets may be appropriate 1
Critical Warning About Asymptomatic Hypoglycemia
Never ignore asymptomatic hypoglycemia or assume it is less dangerous than symptomatic episodes—it indicates impaired defenses and predicts severe events. 2 Asymptomatic hypoglycemia creates a vicious cycle by shifting glycemic thresholds lower and causing further episodes without warning. 2 Screen for this at every clinical encounter in all at-risk individuals. 2