Primary prevention
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Beleid bij acute hypoglykemie met verminderd bewustzijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022La prise en charge de l’hypoglycémie aiguë chez un patient présentant une diminution de la consciencePublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022The American Diabetes Association (ADA) advises that a multicomponent hypoglycaemia prevention plan is critical to caring for individuals at risk for hypoglycaemia.[3] Hypoglycaemia prevention begins by establishing an individual’s hypoglycaemia history and risk factors, including the presence or absence of hypoglycaemia awareness.[3]
Patient and family/carer education
Structured education for hypoglycaemia prevention and treatment is critical and has been shown to improve hypoglycaemia outcomes.[3] Education should ideally be provided through a diabetes self-management education and support programme or by a trained diabetes care and education consultants.[3] Ensure that patients and their family or carers understand:
How to recognise signs and symptoms of hypoglycaemia.[1][2]
How to treat an episode of hypoglycaemia with glucose and glucagon.[2] Note that administration of glucagon is not limited to healthcare professionals and may be given by family or carers if needed; anyone who is in close contact with a patient who is prone to hypoglycaemia (e.g., family members, room-mates, school personnel, childcare providers, correctional institution staff, or co-workers) should be educated on how to administer glucagon.[3] Ensure glucagon is prescribed for all patients on insulin or at high risk of hypoglycaemia.[3]
Circumstances in which the patient is at increased risk of hypoglycaemia (e.g., when fasting for laboratory tests or procedures, when meals are delayed, during and after the consumption of alcohol, during periods of illness, during and after intense exercise, or during sleep).[1][3][17][37] Educate the patient and their family or carers on how to adjust their insulin doses in these scenarios to reduce the risk of hypoglycaemia.[36][37]
The importance and logistics (e.g., how, and how often, to test) of blood glucose self-monitoring.[3]
The requirement to avoid driving with hypoglycaemia.[3]
Patients may benefit from formal training programmes, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycaemia.[2][3][4][17][57][74] Children and young people with diabetes should also have a school healthcare plan detailing their current diabetic treatments, and this should be reviewed by their diabetes team at least once a year.[37]
Pharmacotherapy
Consider an individual’s risk for hypoglycaemia when selecting diabetes drugs and glycaemic goals.[3] Re-evaluate the diabetes treatment plan regularly, with deintensification, simplification, or drug modification as appropriate.[3] Drugs that are associated with increased risk of hypoglycaemia include insulin, sulfonylureas, and meglitinides, and combinations of these drugs are not usually recommended.[17][75] 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 hypoglycaemia.[75][76]
It should be noted that different types or formulations of insulin may be associated with increased risks of hypoglycaemia.[77] For example, premixed insulin injections (which combine short-acting and long-acting insulin) may have a higher hypoglycaemia risk, and it is harder for patients to adjust their dose.[75][77] For adults and children who are taking insulin and at high risk of hypoglycaemia, guidance from the Endocrine Society recommends using:[17]
Long-acting insulin analogues instead of human neutral protamine Hagedorn (NPH) insulin if they are on basal insulin therapy
Rapid-acting insulin analogues rather than regular (short-acting) human insulins if they are on basal-bolus insulin therapy.
Blood glucose monitoring
Blood glucose monitoring is key for the prevention of hypoglycaemia in all patients with type 1 diabetes, and may be appropriate for some patients with type 2 diabetes.[2][3][4][78][79]
Traditionally, self-monitoring of blood glucose (SMBG) using fingerstick measurements has been the primary method, providing point-in-time glucose values. However, SMBG offers limited insight into glucose trends and variability, making it challenging to detect asymptomatic or nocturnal hypoglycaemia and to adjust insulin therapy accurately.
Continuous glucose monitoring (CGM) has transformed diabetes management for insulin-treated patients with both type 1 and type 2 diabetes. CGM provides real-time, dynamic data on glucose levels, trends, and fluctuations, offering a more comprehensive picture of glycaemic control than SMBG. There are two main types of CGM system: real-time, which provides continuous updates; and intermittently scanned, which requires the user to scan the device to obtain glucose values. Most CGM devices report interstitial glucose values every 5 minutes, allowing patients and clinicians to track glucose patterns, optimise therapy, and respond promptly to changes. CGM is especially valuable for detecting and preventing hypoglycaemia: it can identify asymptomatic hypoglycaemia, reveal patterns and triggers, and provide real-time alarms to alert patients of rapidly falling glucose levels, enabling timely interventions.[3] The ADA specifically recommends CGM for all insulin-treated patients, especially those on multiple daily injections or continuous subcutaneous insulin infusion, based on strong evidence that it improves safety and outcomes.[3] Numerous studies have demonstrated that CGM use improves glycaemic control, reduces time spent in hypoglycaemia, and increases time in the target glucose range (3.9 to 10.0 mmol/L ([70-180 mg/dL]).[3]
See Monitoring.
Use of insulin pumps
Insulin pumps with automated low-glucose suspend and automated insulin delivery systems are effective in reducing hypoglycaemia in patients with type 1 diabetes.[3]
Dietary intervention
All patients taking insulin, sulfonylureas, or meglitinides 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 secretagogues 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]
Managing planned fasting
For individuals using insulin or insulin secretagogues, fasting (e.g., for cultural or religious reasons) may increase the risk of hypoglycaemia without proper planning. It is important to proactively engage these individuals prior to a planned period of fasting to create a diabetes treatment plan that ensures safety while honouring their traditions.[3]
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][36][37] Hypoglycaemia leading up to physical activity increases the risk of exercise-induced hypoglycaemia, and patients should usually be advised against exercising within 24 hours of a severe hypoglycaemic episode.[36] Patients should also ensure that they have fast-acting carbohydrates with them at all times when exercising.[2][37] If a patient is taking insulin, they should consider adjusting the insulin doses on the days when exercise is planned.[2][36] 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 hypoglycaemia.[36] Patients should also be advised not to consume alcohol where possible on days they are exercising.[36] The International Society for Pediatric and Adolescent Diabetes advocates that exercise planning should be individualised, reviewed often, and have a focus on hypoglycaemia avoidance strategies.[36] Athletes using insulin should be managed by a diabetes team with consultant exercise knowledge.[36]
Secondary prevention
Take appropriate action, depending on the underlying cause of hypoglycaemia, to mitigate against further episodes of hypoglycaemia.[1] The American Diabetes Association (ADA) recommends a multi-faceted approach for the secondary prevention of hypoglycaemia in patients with diabetes, focusing on education, individualised treatment, and technology use.[3] Measures used should be in addition to those used for primary prevention.
Adjust the patient's treatment for diabetes based on their risk of hypoglycaemia.[2][3] This is particularly important if they have impaired awareness of hypoglycaemia.[3]
HbA1c goals should be individualised and reassessed at regular intervals. The ADA recommends a target HbA1c goal of <7% (<53 mmol/mol) for most nonpregnant adults, adolescents, and children, but notes that less stringent goals (e.g., <7.5% to 8.0% [58-64 mmol/mol]) may be appropriate for people with a history of severe or frequent hypoglycaemia.[3]
Review the patient's blood glucose patterns, which may suggest periods of the day where they are at risk of hypoglycaemia.[2]
If the patient has recurrent hypoglycaemia and type 1 diabetes, consider strategies such as adjustment of the patient's insulin regimen (e.g., use of flexible insulin or insulin analogue regimens, substitution of rapid-acting insulin for neutral insulin), as well as incorporating diabetes technology (e.g., continuous glucose monitoring [CGM] systems, insulin pump therapy, or automated insulin delivery [AID] systems), if not already in use, to monitor and deliver insulin more effectively.[1][2][4][37][57] Some trials and studies have shown that these technologies can reduce the time spent in a hypoglycaemic range (blood glucose <3.9 mmol/L [<70 mg/dL]).[1][129][130] The ADA states that integration of CGM into the treatment plan soon after diagnosis improves glycaemic outcomes, decreases hypoglycaemic events, and improves quality of life for individuals with type 1 diabetes.[3] Accordingly, its use is now considered standard of care for most people with type 1 diabetes. The ADA further recommends AID systems (which integrate CGM) as the preferred insulin delivery method for all patients with type 1 diabetes (contingent upon the individual's [or carer's] capacity for safe device operation).[3] Insulin pump therapy alone should be offered to people on multiple daily injections [MDI] if they are unable to use AID systems.[3] See Type 1 diabetes.
Pancreas and islet cell transplantation may also be used in certain patients, and can improve glycaemic control and survival rates.[131][132] See Type 1 diabetes.
For patients with type 2 diabetes and recurrent hypoglycaemia, it is crucial to review their drug history and, where possible, avoid glucose-lowering drugs known to increase hypoglycaemia risk, such as insulin, sulfonylureas, and meglitinides. Drugs like metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors, which are associated with low risk of hypoglycaemia, may be more suitable.[75][76] The ADA recommends CGM for people with diabetes on any type of insulin therapy, and suggests that its use should also be considered for adults with type 2 diabetes treated with glucose-lowering drugs other than insulin.[3] Furthermore, it recommends that insulin pump therapy, preferably with CGM, should be offered to patients with type 2 diabetes treated with MDI, provided that they can use the device safely.[3] The first AID system to receive Food and Drug Administration (FDA) approval in the US for use in adults with type 2 diabetes was approved in 2024, highlighting their growing role in managing this population.[133] Due to the risk of hypoglycaemia associated with insulin, NICE guidance emphasises avoiding insulin where possible in paediatric patients with type 2 diabetes, instead giving preference to oral antidiabetic drugs that are low risk for hypoglycaemia.[37] They also recommend downtitration or withdrawal of insulin therapy in this group of patients when possible.[37]
See Type 2 diabetes in adults and Type 2 diabetes in children.
If the patient has prolonged nocturnal hypoglycaemia, consider increased monitoring of overnight blood glucose levels.[1]
Review the patient's food intake, particularly the fat and protein content of meals.[1][57] Consider adding daytime and bedtime snacks if they are taking intermediate-acting insulin.[1]
If hypoglycaemia is related to exercise, consider:[1][36][134]
Snacks before and after exercise
Suspension (or reduction) of the patient's insulin pump before exercise if they are using one
Addition of extra carbohydrates if they are taking insulin and are exercising at peak action of insulin
10-second maximum intensity activity at the end of the exercise session (e.g., sprint).
If a patient has impaired awareness of hypoglycaemia, consider short-term relaxation of glycaemic targets; several weeks of avoidance of hypoglycaemia has been shown to improve counter-regulatory hormone response and impaired awareness of hypoglycaemia.[1][3]
Patients may also benefit from formal training programmes, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycaemia.[2][3][4][57][74]
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