Approach

The main aims of treatment for diabetic hypoglycaemia are to:

  • Restore normoglycaemia promptly[3]

  • Avoid complications and progression to more severe hypoglycaemia[4]

  • Prevent recurrence of hypoglycaemia.​​[1][2][3]​​

Management of diabetic hypoglycaemia is with either intravenous or oral glucose or glucagon (or dasiglucagon), and depends on:

  • Severity of hypoglycaemia

  • Whether the patient is conscious or unconscious and if they can take glucose orally or not

  • Availability of intravenous access.

Level 3 (severe) hypoglycaemia or unconscious or unable to take glucose orally

Level 3 (severe) hypoglycaemia is a severe event with no defined blood glucose threshold, characterised by altered mental and/or physical status requiring assistance for treatment of hypoglycaemia.[1][3][4]​​[17]​​​ In practice, if finger stick testing is not available to confirm hypoglycaemia, start treatment if the patient has typical symptoms and signs of hypoglycaemia.

Give intravenous glucose immediately if the patient has intravenous access.​[1][4][38]

If the patient has recurrent episodes of hypoglycaemia, give a glucose intravenous infusion in order to sustain euglycaemia.[106]

If intravenous access is not available (e.g., in an outpatient setting), give glucagon (or dasiglucagon), although glucose is preferred if available.​[1][3][38]​ 

  • In this setting, glucagon may be given intramuscularly, subcutaneously, or intranasally.[1][107][108]

  • In the UK, emergency treatment with intravenous glucose or glucagon may be given without a prescription via a locally agreed patient group direction if needed.[14] MHRA: patient group directions (PGDs) Opens in new window

  • Note that the administration of glucagon is not limited to healthcare professionals and may be given by family or carers if needed.[3][38][59]​​ 

  • Dasiglucagon is a glucagon analogue that is administered subcutaneously. However, it is not widely used because intranasal glucagon is simpler to administer in practice.

Peripheral venous cannulation animated demonstration
Peripheral venous cannulation animated demonstration

How to insert a peripheral venous cannula into the dorsum of the hand.

Level 1 (alert value) or 2 (clinically significant) hypoglycaemia and conscious and able to take glucose orally

Level 1 (alert value) hypoglycaemia is defined as blood glucose <3.9 mmol/L (<70 mg/dL) and ≥3.0 mmol/L (≥54 mg/dL).[1][3][4]​​[17]​ Level 2 (clinically significant; also referred to as clinically important or serious) hypoglycaemia is defined as blood glucose <3.0 mmol/L (<54 mg/dL).[1][3][4]​​[17]​ In practice, if finger stick testing is not available to confirm hypoglycaemia, start treatment if the patient has typical symptoms and signs of hypoglycaemia.

Give glucose orally, although any form of carbohydrate that contains glucose may be used.​[1][3][38]​​ Examples include glucose tablets, glucose gel, sweetened fluids, or crackers. Avoid foods that also contain fat or protein.[3] Fat may slow glucose absorption and delay recovery.[3] In patients with type 2 diabetes, protein may increase secretion of insulin without increasing the blood glucose level.[3][110]

Give glucagon (or dasiglucagon) as an alternative to glucose if the patient is unwilling to take glucose orally.[3]

  • In the UK, emergency treatment with glucagon may be given without a prescription via a locally agreed patient group direction if needed.[14] MHRA: patient group directions (PGDs) Opens in new window

  • Note that the administration of glucagon is not limited to healthcare professionals and may be given by family or carers if needed.[3][38][59]​​ 

  • Dasiglucagon is a glucagon analogue that is administered subcutaneously. However, it is not widely used because intranasal glucagon is simpler to administer in practice.

Monitoring

Re-check the patient's blood glucose after 10-15 minutes and repeat administration of glucose or glucagon (or dasiglucagon) if the patient is still hypoglycaemic (i.e., blood glucose remains <3.9 mmol/L [<70 mg/dL]).​[1][3][38]​​[106]​​ A maximum of two doses of glucagon (or dasiglucagon) is recommended, but in practice a third dose may be given if necessary. Note that intravenous or oral glucose is preferred if available.[3]

Continue treatment until the hypoglycaemia has resolved.[3]

Prevention of recurrent hypoglycaemia

Once the blood glucose has normalised and the acute symptoms of hypoglycaemia have resolved, advise the patient to eat a meal or snack to avoid recurrence of hypoglycaemia.[3][4][111][112]​​​​[113]

Identify and manage the underlying cause of hypoglycaemia (e.g., adjustment of antidiabetic treatment) to prevent future episodes of hypoglycaemia and reduce complications.​[1][4]​ See Prevention.

Patient and family/carer education is also key to prevention.[1]​​[2][3]​​ See Patient discussions.

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