Diabetic hypoglycaemia
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
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: 2022Please 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
level 3 (severe) hypoglycaemia or unconscious or unable to take glucose orally
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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [17]McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-62. https://academic.oup.com/jcem/article/108/3/529/6880627 http://www.ncbi.nlm.nih.gov/pubmed/36477488?tool=bestpractice.com 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18
In the UK, emergency treatment with intravenous glucose may be given without a prescription via a locally agreed patient group direction.[14]Joint British Diabetes Societies for Inpatient Care (JBDS-IP). The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_01_Hypo_Guideline_with_QR_code_January_2023.pdf 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.[107]Desimone ME, Weinstock RS. Hypoglycemia. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2000 (updated May 2018). https://www.ncbi.nlm.nih.gov/books/NBK279137
Re-check the patient's blood glucose after 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [107]Desimone ME, Weinstock RS. Hypoglycemia. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2000 (updated May 2018). https://www.ncbi.nlm.nih.gov/books/NBK279137
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]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [112]Georgakopoulos K, Katsilambros N, Fragaki M, et al. Recovery from insulin-induced hypoglycemia after saccharose or glucose administration. Clin Physiol Biochem. 1990;8(5):267-72. http://www.ncbi.nlm.nih.gov/pubmed/2103901?tool=bestpractice.com [113]McTavish L, Corley B, Weatherall M, et al. Weight-based carbohydrate treatment of hypoglycaemia in people with Type 1 diabetes using insulin pump therapy: a randomized crossover clinical trial. Diabet Med. 2018 Mar;35(3):339-46. http://www.ncbi.nlm.nih.gov/pubmed/29285796?tool=bestpractice.com [114]McTavish L, Wiltshire E. Effective treatment of hypoglycemia in children with type 1 diabetes: a randomized controlled clinical trial. Pediatr Diabetes. 2011 Jun;12(4 pt 2):381-7. http://www.ncbi.nlm.nih.gov/pubmed/21443586?tool=bestpractice.com
Identify and manage the underlying cause of hypoglycaemia (e.g., adjustment of glucose-lowering treatment) to prevent future episodes of hypoglycaemia and reduce complications.[1]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com See Prevention.
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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [17]McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-62. https://academic.oup.com/jcem/article/108/3/529/6880627 http://www.ncbi.nlm.nih.gov/pubmed/36477488?tool=bestpractice.com 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18
In the UK, emergency treatment with glucagon may be given without a prescription via a locally agreed patient group direction.[14]Joint British Diabetes Societies for Inpatient Care (JBDS-IP). The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_01_Hypo_Guideline_with_QR_code_January_2023.pdf 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]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [57]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [107]Desimone ME, Weinstock RS. Hypoglycemia. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2000 (updated May 2018). https://www.ncbi.nlm.nih.gov/books/NBK279137 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 glucagonDose refers to generic glucagon. Dose may depend on the brand of glucagon used. Consult product literature for more information.
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
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.[4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [112]Georgakopoulos K, Katsilambros N, Fragaki M, et al. Recovery from insulin-induced hypoglycemia after saccharose or glucose administration. Clin Physiol Biochem. 1990;8(5):267-72. http://www.ncbi.nlm.nih.gov/pubmed/2103901?tool=bestpractice.com [113]McTavish L, Corley B, Weatherall M, et al. Weight-based carbohydrate treatment of hypoglycaemia in people with Type 1 diabetes using insulin pump therapy: a randomized crossover clinical trial. Diabet Med. 2018 Mar;35(3):339-46. http://www.ncbi.nlm.nih.gov/pubmed/29285796?tool=bestpractice.com [114]McTavish L, Wiltshire E. Effective treatment of hypoglycemia in children with type 1 diabetes: a randomized controlled clinical trial. Pediatr Diabetes. 2011 Jun;12(4 pt 2):381-7. http://www.ncbi.nlm.nih.gov/pubmed/21443586?tool=bestpractice.com
Identify and manage the underlying cause of hypoglycaemia (e.g., adjustment of glucose-lowering treatment) to prevent future episodes of hypoglycaemia and reduce complications.[1]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com See Prevention.
level 1 (alert value) or 2 (clinically significant) hypoglycaemia and conscious and able to take glucose orally
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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [17]McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-62. https://academic.oup.com/jcem/article/108/3/529/6880627 http://www.ncbi.nlm.nih.gov/pubmed/36477488?tool=bestpractice.com 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [17]McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-62. https://academic.oup.com/jcem/article/108/3/529/6880627 http://www.ncbi.nlm.nih.gov/pubmed/36477488?tool=bestpractice.com 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 Examples include glucose tablets, glucose gel, sweetened fluids, or crackers. Most individuals should ingest 15 g of carbohydrates. However, those using automated insulin delivery systems should ingest only 5-10 g, unless hypoglycaemia occurs with exercise or there was a significant overestimation of a carbohydrate/meal bolus.[3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 Avoid foods that also contain fat or protein.[3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 Fat may slow glucose absorption and delay recovery.[3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 In patients with type 2 diabetes, protein may increase secretion of insulin without increasing the blood glucose level.[3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [111]Layman DK, Clifton P, Gannon MC, et al. Protein in optimal health: heart disease and type 2 diabetes. Am J Clin Nutr. 2008 May;87(5):1571-5S. https://www.sciencedirect.com/science/article/pii/S0002916523236679 http://www.ncbi.nlm.nih.gov/pubmed/18469290?tool=bestpractice.com
Re-check the patient's blood glucose after 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [107]Desimone ME, Weinstock RS. Hypoglycemia. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2000 (updated May 2018). https://www.ncbi.nlm.nih.gov/books/NBK279137
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]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [112]Georgakopoulos K, Katsilambros N, Fragaki M, et al. Recovery from insulin-induced hypoglycemia after saccharose or glucose administration. Clin Physiol Biochem. 1990;8(5):267-72. http://www.ncbi.nlm.nih.gov/pubmed/2103901?tool=bestpractice.com [113]McTavish L, Corley B, Weatherall M, et al. Weight-based carbohydrate treatment of hypoglycaemia in people with Type 1 diabetes using insulin pump therapy: a randomized crossover clinical trial. Diabet Med. 2018 Mar;35(3):339-46. http://www.ncbi.nlm.nih.gov/pubmed/29285796?tool=bestpractice.com [114]McTavish L, Wiltshire E. Effective treatment of hypoglycemia in children with type 1 diabetes: a randomized controlled clinical trial. Pediatr Diabetes. 2011 Jun;12(4 pt 2):381-7. http://www.ncbi.nlm.nih.gov/pubmed/21443586?tool=bestpractice.com
Identify and manage the underlying cause of hypoglycaemia (e.g., adjustment of glucose-lowering treatment) to prevent future episodes of hypoglycaemia and reduce complications.[1]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com See Prevention.
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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [17]McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-62. https://academic.oup.com/jcem/article/108/3/529/6880627 http://www.ncbi.nlm.nih.gov/pubmed/36477488?tool=bestpractice.com 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]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [17]McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-62. https://academic.oup.com/jcem/article/108/3/529/6880627 http://www.ncbi.nlm.nih.gov/pubmed/36477488?tool=bestpractice.com 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 unable or unwilling to take glucose orally.[3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1
In the UK, emergency treatment with glucagon may be given without a prescription via a locally agreed patient group direction.[14]Joint British Diabetes Societies for Inpatient Care (JBDS-IP). The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_01_Hypo_Guideline_with_QR_code_January_2023.pdf 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]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [57]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 15 minutes and repeat administration of glucagon (or dasiglucagon) if blood glucose remains <3.9 mmol/L [<70 mg/dL]).[1]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [3]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [107]Desimone ME, Weinstock RS. Hypoglycemia. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2000 (updated May 2018). https://www.ncbi.nlm.nih.gov/books/NBK279137 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 glucagonDose refers to generic glucagon. Dose may depend on the brand of glucagon used. Consult product literature for more information.
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
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]American Diabetes Association. Standards of care in diabetes - 2025. Diabetes care. 2025. Jan 1; 48(Suppl 1):S1-343. https://diabetesjournals.org/care/issue/48/Supplement_1 [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com [37]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng18 [112]Georgakopoulos K, Katsilambros N, Fragaki M, et al. Recovery from insulin-induced hypoglycemia after saccharose or glucose administration. Clin Physiol Biochem. 1990;8(5):267-72. http://www.ncbi.nlm.nih.gov/pubmed/2103901?tool=bestpractice.com [113]McTavish L, Corley B, Weatherall M, et al. Weight-based carbohydrate treatment of hypoglycaemia in people with Type 1 diabetes using insulin pump therapy: a randomized crossover clinical trial. Diabet Med. 2018 Mar;35(3):339-46. http://www.ncbi.nlm.nih.gov/pubmed/29285796?tool=bestpractice.com [114]McTavish L, Wiltshire E. Effective treatment of hypoglycemia in children with type 1 diabetes: a randomized controlled clinical trial. Pediatr Diabetes. 2011 Jun;12(4 pt 2):381-7. http://www.ncbi.nlm.nih.gov/pubmed/21443586?tool=bestpractice.com
Identify and manage the underlying cause of hypoglycaemia (e.g., adjustment of glucose-lowering) to prevent future episodes of hypoglycaemia and reduce complications.[1]Abraham MB, Karges B, Dovc K, et al. ISPAD Clinical Practice Consensus Guidelines 2022: assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec;23(8):1322-40. https://onlinelibrary.wiley.com/doi/10.1111/pedi.13443 http://www.ncbi.nlm.nih.gov/pubmed/36537534?tool=bestpractice.com [4]Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021 Dec;64(12):2609-52. https://link.springer.com/article/10.1007/s00125-021-05568-3 http://www.ncbi.nlm.nih.gov/pubmed/34590174?tool=bestpractice.com 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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