Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

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

1st line – intravenous glucose

Back
ACUTE
|
level 3 (severe) hypoglycaemia or unconscious or unable to take glucose orally
|
with intravenous access
1st line – 

intravenous glucose

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]​​​

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

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

Re-check the patient's blood glucose after 10-15 minutes and repeat administration of glucose until the hypoglycaemia has resolved (i.e., repeat administration if blood glucose remains <3.9 mmol/L [<70 mg/dL]).​[1][3]​​​[38][106]​​​ 

Plus – treat underlying cause and advice

Back
ACUTE
|
level 3 (severe) hypoglycaemia or unconscious or unable to take glucose orally
|
with intravenous access
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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][38][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.

1st line – glucagon or dasiglucagon

Back
ACUTE
|
level 3 (severe) hypoglycaemia or unconscious or unable to take glucose orally
|
without intravenous access
1st line – 

glucagon or dasiglucagon

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.

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 glucagon may be given without a prescription via a locally agreed patient group direction.[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.

Re-check the patient's blood glucose after 10-15 minutes and repeat administration of 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.

In practice, intravenous glucose should be given once intravenous access is available if the patient is still hypoglycaemic following administration of glucagon (or dasiglucagon). See 'with intravenous access' (above).

Primary options

glucagon: children <20 kg body weight: 0.5 mg (or 0.02 to 0.03 mg/kg) subcutaneously/intramuscularly as a single dose, may repeat one dose after 15 minutes if no response; children ≥20 kg body weight and adults: 1 mg subcutaneously/intramuscularly as a single dose, may repeat one dose after 15 minutes if no response

More

OR

glucagon nasal: children ≥4 years of age and adults: 3 mg (1 actuation) into one nostril as a single dose, may repeat one dose after 15 minutes if no response

Secondary options

dasiglucagon: children ≥6 years of age and adults: 0.6 mg subcutaneously as a single dose, may repeat one dose after 15 minutes if no response

Plus – treat underlying cause and advice

Back
ACUTE
|
level 3 (severe) hypoglycaemia or unconscious or unable to take glucose orally
|
without intravenous access
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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][38][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.

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

1st line – oral glucose

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycaemia and conscious and able to take glucose orally
1st line – 

oral glucose

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]​​​

Re-check the patient's blood glucose after 10-15 minutes and repeat administration of glucose until the hypoglycaemia has resolved (i.e., repeat administration if blood glucose remains <3.9 mmol/L [<70 mg/dL]).​[1][3][38][106]​​​

Plus – treat underlying cause and advice

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycaemia and conscious and able to take glucose orally
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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][38][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.

2nd line – glucagon or dasiglucagon

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycaemia and conscious and able to take glucose orally
2nd line – 

glucagon or dasiglucagon

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 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.[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.

Re-check the patient's blood glucose after 10-15 minutes and repeat administration of glucagon (or dasiglucagon) if 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.

Primary options

glucagon: children <20 kg body weight: 0.5 mg (or 0.02 to 0.03 mg/kg) subcutaneously/intramuscularly as a single dose, may repeat one dose after 15 minutes if no response; children ≥20 kg body weight and adults: 1 mg subcutaneously/intramuscularly as a single dose, may repeat one dose after 15 minutes if no response

More

OR

glucagon nasal: children ≥4 years of age and adults: 3 mg (1 actuation) into one nostril as a single dose, may repeat one dose after 15 minutes if no response

Secondary options

dasiglucagon: children ≥6 years of age and adults: 0.6 mg subcutaneously as a single dose, may repeat one dose after 15 minutes if no response

Plus – treat underlying cause and advice

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycaemia and conscious and able to take glucose orally
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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][38][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.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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