Primary prevention
Your Organizational Guidance
ebpracticenet urges you to prioritize the following organizational 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 hypoglycemia prevention plan is critical to caring for individuals at risk for hypoglycemia.[3] Hypoglycemia prevention begins by establishing an individual’s hypoglycemia history and risk factors, including the presence or absence of hypoglycemia awareness.[3]
Patient and family/caregiver education
Structured education for hypoglycemia prevention and treatment is critical and has been shown to improve hypoglycemia outcomes.[3] Education should ideally be provided through a diabetes self-management education and support program or by a trained diabetes care and education specialists.[3] Ensure that patients 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 on insulin or at high risk of hypoglycemia.[3]
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 periods of illness, during and after intense exercise, or 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.[36][72]
The importance and logistics (e.g., how, and how often, to test) of blood glucose self-monitoring.[3]
The requirement to avoid driving with hypoglycemia.[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][17][73]
Pharmacotherapy
Consider an individual’s risk for hypoglycemia when selecting diabetes drugs and glycemic goals.[3] Reevaluate the diabetes treatment plan regularly, with deintensification, simplification, or drug modification as appropriate.[3] Drugs that are associated with increased risk of hypoglycemia include insulin, sulfonylureas, and meglitinides, and combinations of these drugs are not usually recommended.[17][74] 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.[74][75]
It should be noted that different types or formulations of insulin may be associated with increased risks of hypoglycemia.[76] 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.[74][76] 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 the prevention of hypoglycemia in all patients with type 1 diabetes, and may be appropriate for some patients with type 2 diabetes.[2][3][4][77][78]
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 hypoglycemia 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 glycemic 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, optimize therapy, and respond promptly to changes. CGM is especially valuable for detecting and preventing hypoglycemia: it can identify asymptomatic hypoglycemia, 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 glycemic control, reduces time spent in hypoglycemia, and increases time in the target glucose range (70-180 mg/dL [3.9 to 10.0 mmol/L]).[3]
See Monitoring.
Use of insulin pumps
Insulin pumps with automated low-glucose suspend and automated insulin delivery systems are effective in reducing hypoglycemia 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 hypoglycemia 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 honoring 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] 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.[36] 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][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 hypoglycemia.[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 individualized, reviewed often, and have a focus on hypoglycemia avoidance strategies.[36] Athletes using insulin should be managed by a diabetes team with specialist exercise knowledge.[36]
The table that follows summarizes recommendations for primary prevention of hypoglycemia taken from the American Diabetes Association (ADA) standards of care in diabetes.[3]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult with type 1 or type 2 diabetes; at risk for hypoglycemia
This includes those treated with insulin, sulfonylureas, or meglitinides.
All
Intervention
Structured patient education for hypoglycemia prevention and treatment
Provide education via a diabetes self-management education and support program or by a trained diabetes educator, if available.
If structured education is not available, it is recommended that clinicians educate people at risk for hypoglycemia on:
Hypoglycemia definitions
Situations that may precipitate hypoglycemia (fasting, delayed meals, physical activity, and illness)
Blood glucose self-monitoring
Avoidance of driving with hypoglycemia
Step-by-step instructions on hypoglycemia treatment including when and how to use fast-tasting carbohydrates
Glucagon use (as appropriate)
Goal
Improved hypoglycemia outcomes
Structured patient education is recommended (as a minimum):
Routinely for all people at risk for hypoglycemia at the initial patient visit.
At every follow-up visit, and also annually, for those with recurrent hypoglycemic events or at initiation of medication with a high risk for hypoglycemia.
Taking insulin, or at high risk for hypoglycemia
Intervention
Glucagon prescription and training
Prescribing glucagon for all people treated with insulin, or at high risk for hypoglycemia.
Training on safe administration of glucagon is recommended for those in close contact with (or having custodial care of) those prescribed glucagon, including:
Family members
Roommates
Correctional institutional staff
Coworkers
It is essential to explicitly emphasize to never administer insulin to people experiencing hypoglycemia.
Goal
Improved hypoglycemia outcomes
Glucagon review and training is recommended (as a minimum):
At the initial and annual visits.
Undergoing exercise and taking insulin and/or insulin secretagogues
Intervention
Patient education and self glucose monitoring
Individuals on these therapies may need to ingest some added carbohydrate if pre-exercise glucose levels are <90 mg/dL (<5.0 mmol/L), depending on several factors including:
Whether they are able to lower insulin doses during the workout (such as with an insulin pump or reduced pre-exercise insulin dosage).
The time of day exercise is done.
The intensity and duration of the activity.
In some people with diabetes, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity.
Advise people with diabetes to check blood glucose levels or consult sensor glucose values before and after periods of exercise. Education about the potential prolonged effects (depending on intensity and duration) is also recommended.
Goal
Prevention of exercise-induced hypoglycemia
With alcohol use
Intervention
Patient education on safe alcohol use
Educate people with diabetes about these risks and encourage them to monitor glucose frequently after drinking alcohol to minimize such risks.
Risks associated with alcohol consumption include hypoglycemia and/or delayed hypoglycemia (particularly for those using insulin or insulin secretagogues [i.e., sulfonylureas, meglitinides]).
Goal
Avoidance of alcohol related harm, including hypoglycemia
Advise people with diabetes to follow the same guidelines as those without diabetes.
To reduce risk of alcohol-related harms, adults can choose not to drink or to drink in moderation by limiting intake to:
≤2 drinks a day for men
≤1 drink a day for women
(One drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits).
With initiation of new drugs
Intervention
Reevaluation of diabetes treatment plan
When initiating a new glucose-lowering medication, reassess the need for and/or dose of medications with higher hypoglycemia risk.
Be aware of drug-drug interactions that may precipitate hypoglycemia; this could include nonprescription medications, and herbal and dietary supplements.
Notably, sulfonylureas may interact with a number of commonly used antibiotics, which may enhance the hypoglycemic effect of the sulfonylurea, leading to hypoglycemia.
Follow guidance as per your relevant drug information source; it may be necessary to consider temporarily decreasing the dose of or stopping an antidiabetic medication in this situation.
Goal
Minimization of hypoglycemia and treatment burden
With intercurrent illness
Intervention
Reevaluation of diabetes treatment plan
Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose.
Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.
Goal
Prevention of hypoglycemia (and life-threatening conditions related to hyperglycemia)
Pregnant or postpartum
Intervention
Patient education; individualized glycemic goal; consider CGM
Pregnant women with type 1 diabetes have an increased risk of hypoglycemia in the first trimester.
Pregnant women with both type 1 and type 2 diabetes have altered counterregulatory responses in pregnancy that may decrease hypoglycemia awareness.
Educate all pregnant women and their family members about the prevention, recognition and treatment of hypoglycemia.
Glycemic goals in pregnancy are stricter than in nonpregnant individuals; it is therefore important to advise that pregnant women with diabetes eat consistent amounts of carbohydrates to match with insulin dosage and to avoid hyperglycemia or hypoglycemia. If an individual cannot achieve these goals without significant hypoglycemia, the ADA suggests less stringent goals based on clinical experience and individualization of care.
CGM can help to achieve glycemic goals in type 1 diabetes during pregnancy.
Insulin resistance drops rapidly with the delivery of the placenta. Insulin sensitivity then returns to prepregnancy levels over the following 1-2 weeks.
For all postpartum women taking insulin, pay particular attention to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules. Lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted.
Goal
Prevention or early detection of hypoglycemia
Education is recommended before, during and after pregnancy to help prevent and manage hypoglycemia risk.
Older adult living in a long-term care facility
Intervention
Consider development of a glycemia alert strategy; consider CGM
Care facility staff are advised to call a healthcare professional as soon as possible when:
Glucose values are 70-100 mg/dL (3.9 to 5.6 mmol/L); in this situation, the treatment plan may need to be adjusted.
The person is sick, with vomiting or poor oral intake.
Risk factors include:
Impaired renal function
Suboptimal hydration
Variable appetite and nutritional intake
Polypharmacy
Recommend CGM for all older adults with type 1 diabetes, and for all older adults with type 2 diabetes on insulin therapy.
CGM may be a useful approach to monitoring for hypoglycemia among individuals treated with insulin in long-term care, but data are limited. The individual must be capable of using the device safely (either by themselves or with a caregiver).
Goal
Timely adjustment of glycemic treatment; prevention of hypoglycemia
In practice, such an alert strategy would include notifications for both hypoglycemia and hyperglycemia (although the latter is not included within this table). Hypoglycemia and symptomatic hyperglycemia must be managed immediately.
Healthcare professionals may adjust treatment plans by telephone, fax, or in person directly at the long-term care facility, depending on service arrangements and clinical urgency.
Using insulin or other glucose-lowering medication and capable of safely using a CGM device
Intervention
Consider CGM
Consider the use of CGM devices from the outset of diagnosis for all people whose diabetes requires insulin management.
CGM is recommended for all adults (including older adults) with diabetes on any type of insulin therapy.
Consider using CGM in adults with type 2 diabetes treated with glucose-lowering medications other than insulin.
It is recommended that the choice of device is made based on the individual’s circumstances, preferences and needs.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
CGM is particularly useful (and is recommended) in people with diabetes who are at risk for hypoglycemia. CGM can reveal asymptomatic hypoglycemia and help identify patterns and precipitants of hypoglycemic events.
Real-time CGM can provide alarms that can warn people of falling glucose so that they can intervene.
Goal
Reduced rates of hypoglycemia; improved glycemic outcomes
Consideration of continuous glucose monitoring needs is recommended at all clinical encounters (initial visit, all follow-up visits and the annual visit).
Admitted to hospital
Intervention
Increased vigilance for hypoglycemia; interdisciplinary prevention strategy
Common preventable sources of iatrogenic hypoglycemia within a hospital setting include errors in insulin dosing, missed doses and/or administration errors including incorrect insulin type and timing of dose.
Proactive surveillance of glycemic outliers and an interdisciplinary data-driven approach to glycemic management can reduce or prevent hypoglycemic episodes.
Be aware of and mitigate against preventable causes of hypoglycemia in the inpatient setting, including:
A sudden reduction in corticosteroid dose
Reduced oral intake
Emesis
Inappropriate timing of short- or rapid-acting insulin doses in relation to meals
Reduced infusions rates of intravenous dextrose
Unexpected interruption or enteral or parenteral feedings
Delayed or missed glucose checks
Altered ability of the individual to report symptoms
Goal
Reduced rates of hypoglycemia
With fasting for religious or cultural reasons
Intervention
Patient education and support
Fasting is a major risk factor for hypoglycemia. It may increase the risk for hypoglycemia among people treated with insulin or insulin secretagogues (i.e., sulfonylureas, meglitinides) if not properly planned for. Duration, frequency, and type of fast vary among different religions.
Use an established tool such as the International Diabetes Federation and Diabetes and Ramadan International Alliance (IDF-DAR) comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.
Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.
Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.
Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake. Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.
Goal
Prevention of hypoglycemia
With impaired or declining cognitive function
Intervention
Increased vigilance for hypoglycemia; consider a less stringent HbA1c goal
The presence of impaired or declining cognitive function indicates a need for increased vigilance for hypoglycemia by the clinician, patient, and caregivers; this is considered a major risk factor for hypoglycemia.
A less stringent HbA1c goal is appropriate for those with significant cognitive impairment, in whom the harms of treatment are greater than the benefits.
Goal
Improved hypoglycemia outcomes; balance of risks (including hypoglycemia) and benefits of glycemic treatment
Selection of glycemic goals in older adults with intermediate or complex health is individualized, with less stringent goals (such as HbA1c <8.0% [<64 mmol/mol]) recommended for those with significant cognitive and/or functional limitations, frailty, severe comorbidities, and a less favorable risk-to-benefit ratio of diabetes medications.
If using an ambulatory glucose profile/glucose management indicator to assess glycemia, a parallel goal for those with frailty or at high risk of hypoglycemia is >50% TIR, with <1% time below range recommended.
Older adults with very complex or poor health receive minimal benefit from stringent glycemic control; in this situation, it is recommended that clinicians avoid reliance on glycemic goals and instead focus on avoiding hypoglycemia and symptomatic hyperglycemia.
Child or adolescent with type 1 or type 2 diabetes; at risk for hypoglycemia
All children treated with insulin are considered at risk for hypoglycemia; this includes all children with type 1 diabetes. In general there is a low risk of hypoglycemia in youth with type 2 diabetes, even if they are being treated with insulin.
Structured patient education for hypoglycemia prevention and treatment; consider glucagon prescription and training
Intervention
Structured patient education for hypoglycemia prevention and treatment; consider glucagon prescription and training
Structured patient education for hypoglycemia prevention and treatment:
Provide education via a diabetes self-management education and support program or by a trained diabetes educator, if available.
If structured education is not available, it is recommended that clinicians educate the child or youth at risk for hypoglycemia (and their family members/carers) on:
Hypoglycemia definitions
Situations that may precipitate hypoglycemia (fasting, delayed meals, physical activity, and illness)
Blood glucose self-monitoring
Avoidance of driving with hypoglycemia
Step-by-step instructions on hypoglycemia treatment, including when and how to use fast-acting carbohydrates
Glucagon use
Glucagon prescription and training:
Prescribe glucagon for all people treated with insulin.
Training on safe administration of glucagon is recommended for those in close contact with (or having custodial care of) those prescribed glucagon, including:
Family members
School personnel
Childcare professionals
It is essential to explicitly emphasize to never administer insulin to people experiencing hypoglycemia.
Goal
Improved hypoglycemia outcomes
Structured patient education for hypoglycemia prevention and treatment:
Structured patient education is recommended (as a minimum):
Routinely for all people at risk for hypoglycemia at the initial patient visit.
At every follow-up visit, and also annually, for those with recurrent hypoglycemic events or at initiation of medication with a high risk for hypoglycemia.
Glucagon prescription and training:
Glucagon review and training is recommended (as a minimum):
At both the initial and annual visits.
Attending school or childcare setting
Intervention
Provider training in accordance with the individual’s diabetes treatment plan
It is recommended that the diabetes team assesses the educational needs and skills of, and provides training to, daycare workers, school nurses, and school personnel who are responsible for the care and supervision of the child with diabetes.
It is important that students are supported at school in the use of diabetes technology, including continuous glucose monitors, insulin pumps, connected insulin pens, and automated insulin delivery systems as prescribed by their diabetes care team.
Goal
Safe access to the school or daycare environment, including prevention of hypoglycemia
Young child (age <6 years) with type 1 diabetes
Intervention
Enhanced clinical surveillance and individualized prevention strategies
Special consideration to the risk of hypoglycemia is needed in young children with type 1 diabetes who are often unable to recognize, articulate, and/or manage hypoglycemia.
Potential prevention strategies include:
Individualized glycemic goals
Patient, family and caregiver education
Nutrition intervention (e.g., bedtime snack to prevent overnight hypoglycemia when specifically needed to treat low blood glucose)
Physical activity management
Medication adjustment
Goal
Improved hypoglycemia outcomes
Undergoing exercise; with type 1 diabetes
Intervention
Patient and caregiver education and self glucose monitoring
Educate youth and their parents/caregivers on goals and management of glycemia before, during, and after physical activity, individualized according to the type and intensity of the planned physical activity.
Strategies may include reducing prandial insulin dosing for the meal/snack preceding (and, if needed, following) exercise, reducing basal insulin doses, increasing carbohydrate intake, eating bedtime snacks, frequent glucose monitoring before, during, and after exercise, via blood glucose meter or continuous glucose monitoring (CGM).
Consider additional carbohydrate intake during and/or after exercise, depending on the duration and intensity of physical activity, to prevent hypoglycemia:
For low- to moderate-intensity aerobic activities (30-60 minutes), and if the youth is fasting, 10-15 g of carbohydrate may prevent hypoglycemia.
After insulin boluses (relative hyperinsulinemia), consider 0.5 to 1.0 g of carbohydrates/kg per hour of exercise (∼30-60 g), which is similar to carbohydrate requirements to optimize performance in athletes without type 1 diabetes.
It is recommended that treatment for hypoglycemia is accessible before, during, and after engaging in activity.
Goal
Prevention of exercise-induced hypoglycemia
It is recommended that blood glucose goals prior to physical activity and exercise are 126-180 mg/dL (7.0-10.0 mmol/L); individualization is necessary based on the type, intensity, and duration of activity.
Youth on insulin pumps without automated insulin delivery can lower basal rates by ∼10-50% or more or suspend for 1-2 hours during exercise.
Decreasing basal rates or long-acting insulin doses by ∼20% after exercise may reduce delayed exercise-induced hypoglycemia.
Taking insulin, and capable of safely using CGM and/or advanced insulin delivery technology
Intervention
Consider CGM and/or advanced insulin delivery technology
Recommend CGM for diabetes management to youth with diabetes on any type of insulin therapy.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
Offer automated insulin delivery (AID) systems for diabetes management to youth with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers).
Offer insulin pump therapy alone for diabetes management to youth on multiple daily injections with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers) if unable to use AID systems.
The choice of device is dependent on the individual’s and family’s circumstances, desires, and needs.
Goal
Improved glycemic management, including prevention of hypoglycemia
With alcohol use
Intervention
Patient education
Alcohol use has implications for glycemic management and safety in adolescents with diabetes.
Educate patients and their families about the risks of alcohol use, and strategies to minimize risks.
Goal
Avoidance of alcohol-related harm, including hypoglycemia
With fasting for religious or cultural reasons
Intervention
Patient and caregiver education and support
Work with patients and their caregivers to establish a diabetes treatment plan that is safe and culturally sensitive and individualized.
Use an established tool such as the IDF-DAR comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.
Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.
Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.
Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake.
Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.
Goal
Ensure safety whilst maintaining respect of the individual’s traditions
With intercurrent illness
Intervention
Reevaluation of diabetes treatment plan
Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose.
Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.
Goal
Prevention of hypoglycemia
Admitted to hospital
Intervention
Increased vigilance for hypoglycemia; interdisciplinary prevention strategy
Common preventable sources of iatrogenic hypoglycemia within a hospital setting include errors in insulin dosing, missed doses and/or administration errors including incorrect insulin type and timing of dose.
Proactive surveillance of glycemic outliers and an interdisciplinary data-driven approach to glycemic management can reduce or prevent hypoglycemic episodes.
Be aware of and mitigate against preventable causes of hypoglycemia in the inpatient setting, including:
A sudden reduction in corticosteroid dose
Reduced oral intake
Emesis
Inappropriate timing of short- or rapid-acting insulin doses in relation to meals
Reduced infusions rates of intravenous dextrose
Unexpected interruption or enteral or parenteral feedings
Delayed or missed glucose checks
Altered ability of the individual to report symptoms
Goal
Reduced rates of hypoglycemia
Secondary prevention
Take appropriate action, depending on the underlying cause of hypoglycemia, to mitigate against further episodes of hypoglycemia.[1] The American Diabetes Association (ADA) recommends a multifaceted approach for the secondary prevention of hypoglycemia in patients with diabetes, focusing on education, individualized 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 hypoglycemia.[2][3] This is particularly important if they have impaired awareness of hypoglycemia.[3]
HbA1c goals should be individualized 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 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., 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] 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][128][129] The ADA states that integration of CGM into the treatment plan soon after diagnosis improves glycemic outcomes, decreases hypoglycemic 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 caregiver'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 glycemic control and survival rates.[130][131] See Type 1 diabetes.
For patients with type 2 diabetes and recurrent hypoglycemia, it is crucial to review their drug history and, where possible, avoid glucose-lowering drugs known to increase hypoglycemia 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 hypoglycemia, may be more suitable.[74][75] 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.[132]
See Type 2 diabetes in adults and Type 2 diabetes in children.
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][36][133]
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 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 also benefit from formal training programs, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycemia.[2][3][4][73]
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