What are the instructions for managing hypoglycemia (low blood sugar) in a nursing home patient?

From the Guidelines

Hypoglycemia Protocol for Nursing Home Patients: If a resident's blood glucose falls below 70 mg/dL or they show symptoms of hypoglycemia, immediate action is required. For conscious patients who can swallow safely, administer 15-20 grams of fast-acting carbohydrates such as 4 ounces of fruit juice, 4 ounces of regular soda, 1 tablespoon of honey or sugar dissolved in water, or 3-4 glucose tablets, as recommended by the most recent guidelines 1. Wait 15 minutes, then recheck blood glucose. If it remains below 70 mg/dL, repeat the treatment. Once blood glucose exceeds 70 mg/dL, provide a small snack containing protein and complex carbohydrates (like cheese and crackers) if the next meal is more than 30 minutes away. For unconscious patients or those who cannot swallow safely, administer glucagon injection (1 mg intramuscularly for adults) and call emergency services immediately, as suggested by previous studies 1. Position the patient on their side to prevent aspiration. Document the episode, including blood glucose readings, interventions, and the patient's response. Notify the physician of all hypoglycemic events, especially if they occur repeatedly. Review the patient's medication regimen, particularly insulin or sulfonylureas, as dosage adjustments may be necessary, in line with the recommendations for managing diabetes in long-term care facilities 1. Regular monitoring is essential for patients on diabetes medications, with more frequent checks during illness or changes in food intake, as emphasized in the standards of medical care in diabetes 1. This protocol addresses hypoglycemia quickly to prevent serious complications like seizures or loss of consciousness, as elderly patients often have blunted symptoms and may be more vulnerable to cognitive effects of low blood sugar.

Some key points to consider in the protocol include:

• Recognizing the symptoms of hypoglycemia, such as confusion, sweating, shakiness, irritability, dizziness, or weakness
• Administering fast-acting carbohydrates for conscious patients who can swallow safely
• Using glucagon injection for unconscious patients or those who cannot swallow safely
• Providing a small snack containing protein and complex carbohydrates after blood glucose exceeds 70 mg/dL
• Documenting the episode and notifying the physician of all hypoglycemic events
• Reviewing the patient's medication regimen and adjusting as necessary
• Regular monitoring of blood glucose levels, especially during illness or changes in food intake.

By following this protocol, nursing home staff can help prevent and manage hypoglycemia in residents with diabetes, reducing the risk of serious complications and improving overall quality of life, as supported by the most recent and highest quality study 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 hypoglycemia instructions protocol for a nursing home patient is as follows:

• Identify severe hypoglycemia: Recognize the signs and symptoms of severe hypoglycemia and inform those around the patient about Glucagon for Injection and its Instructions for Use.
• Administer Glucagon for Injection: Use the supplied prefilled syringe to reconstitute the Glucagon for Injection powder and inject the solution subcutaneously or intramuscularly in the upper arm, thigh, or buttocks.
• Inspect the solution: Visually inspect the reconstituted solution for particulate matter and discoloration. If the solution is cloudy or contains particulate matter, do not use.
• Dosage: The recommended dosage is 1 mg (1 mL) injected subcutaneously or intramuscularly for adults and pediatric patients weighing more than 25 kg or for pediatric patients with unknown weight 6 years and older.
• Call for emergency assistance: Call for emergency assistance immediately after administering the dose.
• Follow-up care: 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 2.

From the Research

Hypoglycemia Instructions Protocol for a Nursing Home Patient

Definition and Risk Factors

• Hypoglycemia is a major limiting factor to successful glycaemic management in people with diabetes, particularly those with type 1 diabetes and insulin-treated type 2 diabetes 3.
• Therapies for diabetes, such as insulins and insulin secretagogues, increase the risk of hypoglycaemia 3.

Symptoms and Prevention

• Education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention, and treatment of hypoglycaemia 3.
• Awareness of the potential dangers of hypoglycaemia is fundamental to the optimal management of diabetes 3.
• Prevention options include insulin analogues, continuous glucose monitoring, insulin pumps, and dogs that have been trained to detect hypoglycaemia 3.

Treatment

• Glucagon is an emergency medication that can save lives by quickly raising glucose in people who are unconscious or unable to consume glucose due to severe hypoglycaemia 4.
• New formulations of glucagon, such as nasal powder glucagon and liquid-stable glucagon, have become available and offer ease of use, efficacy, and safety 4.
• Mini-dose glucagon may provide an alternative to oral carbohydrates for the management of anticipated, impending, or mild hypoglycaemia in adults with type 1 diabetes 5.

Response to Hypoglycemia

• If a patient experiences symptoms of hypoglycaemia, such as confusion, shakiness, or loss of consciousness, caregivers should administer glucagon according to the patient's treatment plan 4.
• If the patient is unable to consume glucose, caregivers should call for emergency medical assistance 4.
• Caregivers should regularly review the patient's treatment plan and be aware of the potential dangers of hypoglycaemia 3.

Regulatory Implications

• Regulatory bodies have recognized hypoglycaemia as a major limiting factor in controlling glucose levels in diabetes, and have proposed regulatory approaches for recognition and labeling of diabetes therapies to facilitate personalized care 6.
• One insulin preparation is now recognized and labelled as reducing the risk of severe hypoglycaemia 6.