How should acute hypoglycemia be treated and prevented in an adult patient?

Treatment and Prevention of Acute Hypoglycemia in Adults

For any adult with blood glucose ≤70 mg/dL, immediately administer 15-20 grams of pure glucose orally (glucose tablets or solution preferred), recheck glucose at 15 minutes, and repeat the dose if hypoglycemia persists. 1, 2

Immediate Treatment Protocol

First-Line Oral Treatment (Conscious Patients)

• Administer 15-20 grams of pure glucose as soon as blood glucose falls to ≤70 mg/dL 1, 2
• Pure glucose tablets or glucose solution are strongly preferred because the glycemic response correlates more closely with actual glucose content than with total carbohydrate content 1, 2
• A 10-gram dose raises blood glucose by approximately 40 mg/dL within 30 minutes; a 20-gram dose raises it by approximately 60 mg/dL within 45 minutes 2
• Any carbohydrate containing glucose can be used if pure glucose is unavailable, though it is less effective 1, 2
• Sucrose (table sugar) tablets or solution are nearly as effective as glucose tablets 2

Monitoring and Repeat Dosing

• Recheck blood glucose exactly 15 minutes after the initial dose 1, 2
• Expect symptom improvement within 10-20 minutes after glucose ingestion 1, 2
• If glucose remains ≤70 mg/dL at 15 minutes, repeat another 15-20 gram dose 1, 2
• Recheck again at 60 minutes after initial treatment, as glucose levels may begin to fall again after the initial correction 2

Post-Recovery Nutrition

• Once blood glucose normalizes, the patient must consume a meal or snack containing complex carbohydrates and protein (e.g., crackers with cheese or a meat sandwich) to prevent recurrent hypoglycemia 1, 2
• Ongoing insulin activity or insulin secretagogues may lead to recurrent hypoglycemia unless additional food is ingested after recovery 1

Critical Treatment Pitfalls to Avoid

• Do not add fat (chocolate, cookies, ice cream) to the carbohydrate treatment, as fat delays and prolongs the glycemic response 1, 2
• Do not use protein-rich foods alone (cheese, nuts, meat) to treat acute hypoglycemia, because protein can stimulate insulin release without adequately raising glucose, especially in type 2 diabetes 1, 2
• Avoid orange juice as first-line treatment because its fructose content is less effective than glucose for rapid glucose elevation 2
• Never delay treatment while waiting for blood glucose confirmation, though documentation before treatment is ideal when possible 2

Severe Hypoglycemia (Unconscious or Unable to Swallow)

Glucagon Administration

• For patients unable or unwilling to consume oral carbohydrates, administer glucagon immediately via injection or intranasal route 1, 2, 3
• Adults and patients weighing >25 kg or ≥6 years: administer 1 mg (1 mL) subcutaneously, intramuscularly (upper arm, thigh, or buttocks), or intravenously 3
• Patients weighing <25 kg or <6 years: administer 0.5 mg (0.5 mL) via the same routes 3
• If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 3
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration 2
• Call for emergency assistance immediately after administering glucagon 3

Caregiver Education

• Family members and close contacts must be instructed on glucagon administration, including where it is kept and when and how to administer it 2
• Caregivers do not need to be healthcare professionals to safely administer glucagon 1
• Ensure glucagon products are not expired 1

Prevention Strategies

High-Risk Situation Recognition

• Educate patients to recognize situations that increase hypoglycemia risk: fasting for tests or procedures, delayed or skipped meals, during and after alcohol consumption, during and after intense exercise, and during sleep 1, 2
• Hypoglycemia may increase the risk of harm to self or others, such as with driving 1

Hypoglycemia Unawareness Management

• Any episode of level 2 hypoglycemia (<54 mg/dL) or level 3 hypoglycemia (severe event requiring assistance) mandates immediate reevaluation of the treatment regimen 1, 2
• For patients with hypoglycemia unawareness, raise glycemic targets to strictly avoid hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness 2
• Absence of self-monitoring of blood glucose (SMBG) and previous severe hypoglycemic episodes are independent risk factors for severe hypoglycemia requiring medical assistance 4

Medication Considerations

• Consider deintensifying or switching diabetes medications, particularly insulin, sulfonylureas, or meglitinides, when risks exceed benefits 2
• Metformin alone carries minimal hypoglycemia risk and may be used safely during fasting periods 2
• Sulfonylureas (particularly chlorpropamide) carry high risk of prolonged and unpredictable hypoglycemia 2

Patient Preparedness

• Patients at risk must have immediate access to glucose tablets or glucose-containing foods at all times 2
• Document the frequency and severity of hypoglycemic episodes at every visit to identify patterns and triggers 1, 2
• Assess for hypoglycemia unawareness at every patient visit 1

Special Clinical Considerations

• Older patients, those with psychological disorders (insomnia, dementia, depression), rural residents, and those with prolonged duration of hypoglycemia have higher risks of neurological sequelae 4
• Neurological manifestations are the principal reason for hospital admission in 89% of severe hypoglycemia cases, with 20% precipitating convulsions 5
• Hypoglycemia can masquerade as head trauma, seizure activity, or focal neurological deficits, so consider hypoglycemia in all patients with any mental status abnormality even when findings seem explained by other etiologies 6, 7