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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: 2022

The main aims of treatment for diabetic hypoglycemia are to:[1][2][3]​​​​[4]

  • Restore normoglycemia promptly

  • Avoid complications and progression to more severe hypoglycemia

  • Prevent recurrence of hypoglycemia.​

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

  • Severity of hypoglycemia

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

  • Availability of intravenous access.

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

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

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

If the patient has recurrent episodes of hypoglycemia, give a dextrose intravenous infusion in order to sustain euglycemia.[106]

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

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

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

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

Peripheral intravascular catheter: animated demonstration
Peripheral intravascular catheter: animated demonstration

How to insert a peripheral intravascular catheter into the dorsum of the hand.

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

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

Give glucose orally, although any form of carbohydrate that contains glucose may be used.​[1][3]​​​ 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 hypoglycemia occurs with exercise or there was a significant overestimation of a carbohydrate/meal bolus.[3]​​ 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 unable or unwilling to take glucose orally.[3]

Monitoring

Recheck the patient's blood glucose after 15 minutes and repeat administration of dextrose/glucose or glucagon (or dasiglucagon) if the patient is still hypoglycemic (i.e., blood glucose remains <70 mg/dL [<3.9 mmol/L]).​[1][3][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 dextrose or oral glucose is preferred if available.[3]

Continue treatment until the hypoglycemia has resolved.[3]

Prevention of recurrent hypoglycemia

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

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

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

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