Primary prevention

Patient and family/caregiver education

Ensure the patient and their family or caregivers understand:

  • How to recognize signs and symptoms of hypoglycemia.[1][2]​​

  • How to treat an episode of hypoglycemia with glucose and glucagon.[2] Note that administration of glucagon is not limited to healthcare professionals and may be given by family or caregivers if needed; anyone who is in close contact with a patient who is prone to hypoglycemia (e.g., family members, roommates, school personnel, childcare providers, correctional institution staff, or coworkers) should be educated on how to administer glucagon.[3]​ Ensure glucagon is prescribed for all patients at risk of level 2 (clinically significant; also referred to as clinically important or serious) or level 3 (severe) hypoglycemia.[3] Level 2 hypoglycemia is defined as blood glucose <54 mg/dL (<3.0 mmol/L).​[1][3][4][17]​​​ Level 3 hypoglycemia is a severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia.​[1][3][4][17]

  • Circumstances in which the patient is at increased risk of hypoglycemia (e.g., when fasting for laboratory tests or procedures, when meals are delayed, during and after the consumption of alcohol, during and after intense exercise, during sleep).​[1][3]​​[17] Educate the patient and their family or caregiver on how to adjust their insulin doses in these scenarios to reduce the risk of hypoglycemia.[37][70]

Patients may benefit from formal training programs, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycemia.​[2][3][4][17][71]​​​

Dietary intervention

All patients taking antidiabetic drugs should carry carbohydrates with them at all times, and understand the effect of the carbohydrate on their blood glucose.[1][2]​ They should be aware of which foods contain carbohydrates.[2] If a patient is taking long-acting secretagogs or a fixed insulin regimen, encourage them to follow a predictable meal plan.[2] If a patient is on a flexible insulin regimen, ensure they understand that insulin injections should be matched to meal times.[2]

Exercise management

Patients should check their blood glucose before exercising and consume extra carbohydrates based on their blood glucose level (particularly if this is falling) and the planned duration and intensity of exercise.[1][2][37]​ Hypoglycemia leading up to physical activity increases the risk of exercise-induced hypoglycemia, and patients should usually be advised against exercising within 24 hours of a severe hypoglycemic episode.[37]​ Patients should also ensure that they have fast-acting carbohydrates with them at all times when exercising.[2] If a patient is taking insulin, they should consider adjusting the insulin doses on the days when exercise is planned.[2][37]​ Patients who increase their activity levels over time may experience a reduction in their overall insulin requirements due to the sustained increase in insulin sensitivity, and should have insulin dose adjustments made as necessary by their diabetes team to avoid hypoglycemia.[37]​ Patients should also be advised not to consume alcohol where possible on days they are exercising.[37]​ The International Society for Pediatric and Adolescent Diabetes advocates that exercise planning should be individualized, reviewed often, and have a focus on hypoglycemia avoidance strategies.[37]​ Athletes using insulin should be managed by a diabetes team with specialist exercise knowledge.[37]

Medication

In patients with type 2 diabetes, consider the effect of their antidiabetic medication on their risk of hypoglycemia.[72] Drugs that are associated with increased risk of hypoglycemia include insulin, sulfonylureas, and meglitinides, and combinations of these drugs are not usually recommended.[17][72]​​​​ Conversely, metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors are associated with low risk of hypoglycemia.[72][73]​​​

It should be noted that different types or formulations of insulin may be associated with increased risks of hypoglycemia.[74]​ For example, premixed insulin injections (which combine short-acting and long-acting insulin) may have a higher hypoglycemia risk, and it is harder for patients to adjust their dose.[72]​[74]​ For adults and children who are taking insulin and at high risk of hypoglycemia, guidance from the Endocrine Society recommends using:[17]

  • Long-acting insulin analogs instead of human neutral protamine Hagedorn (NPH) insulin if they are on basal insulin therapy

  • Rapid-acting insulin analogs rather than regular (short-acting) human insulins if they are on basal-bolus insulin therapy.

Blood glucose monitoring

Blood glucose monitoring is key for prevention of hypoglycemia in all patients with type 1 diabetes, and may be appropriate for some patients with type 2 diabetes.​[2][3][4][75]​​[76]​​​ See Monitoring.

Secondary prevention

Take appropriate action, depending on the underlying cause of hypoglycemia, to mitigate against further episodes of hypoglycemia.[1]​ Measures used should be in addition to those used for primary prevention.

Adjust the patient's treatment for diabetes based on their risk of hypoglycemia.​[2][3]​​ This is particularly important if they have impaired awareness of hypoglycemia.[3]

  • Review the patient's blood glucose patterns, which may suggest periods of the day where they are at risk of hypoglycemia.[2]

  • If the patient has recurrent hypoglycemia and type 1 diabetes, consider strategies such as adjustment of the patient's insulin regimen (e.g., use of flexible insulin or insulin analog regimens, substitution of rapid-acting insulin for regular insulin), as well as incorporating diabetes technology (e.g., insulin pumps, continuous glucose monitoring) to monitor and deliver insulin more effectively.[1][2][4]​​​ Examples of technology used in diabetes management include sensor-augmented pump therapy (where insulin pump therapy is suspended if hypoglycemia is predicted based on patient-specific set glucose limits) and closed-loop systems (which use a control algorithm that autonomously and continually increases and decreases the delivery of insulin based on real-time sensor blood glucose levels, rather than patient intervention).[1] Some trials and studies have shown that these technologies can reduce the time spent in a hypoglycemic range (blood glucose <70 mg/dL [<3.9 mmol/L]).[1][131][132]​​​​ 

  • Newer technologies (such as artificial pancreas systems) have been shown to improve glucose control and reduce hypoglycemic events in outpatient settings compared to conventional pump therapy.[1] Pancreas and islet cell transplantation may also be used in certain patients, which can improve glycemic control and survival rates.[133][134]​​​

  • If the patient has recurrent hypoglycemia and type 2 diabetes, avoid antidiabetic drugs that increase the risk of hypoglycemia (e.g., insulin, sulfonylureas, and meglitinides). Conversely, metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors are associated with low risk of hypoglycemia.[72][73]​​​​

If the patient has prolonged nocturnal hypoglycemia, consider increased monitoring of overnight blood glucose levels.[1]

Review the patient's food intake, particularly the fat and protein content of meals.[1] Consider adding daytime and bedtime snacks if they are taking intermediate-acting insulin.[1]

If hypoglycemia is related to exercise, consider:[1]

  • Snacks before and after exercise[1][37]​

  • Suspension (or reduction) of the patient's insulin pump before exercise if they are using one[1][37]​​

  • Addition of extra carbohydrates if they are taking insulin and are exercising at peak action of insulin[1][37]​​

  • 10-second maximum intensity activity at the end of the exercise session (e.g., sprint).[135]

If a patient has impaired awareness of hypoglycemia, consider short-term relaxation of glycemic targets; several weeks of avoidance of hypoglycemia has been shown to improve counterregulatory hormone response and impaired awareness of hypoglycemia.​[1][3]

Patients may benefit from formal training programs, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycemia.​[2][3][4][71]​​ For example, the Blood Glucose Awareness Training Program may be useful for patients with recurrent episodes of hypoglycemia.​[2][3][17]​​​

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