Treatment algorithm

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: 2022

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

ACUTE

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

1st line – intravenous dextrose

Back
ACUTE
|
level 3 (severe) hypoglycemia or unconscious or unable to take glucose orally
|
with intravenous access
1st line – 

intravenous dextrose

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]​

Recheck the patient's blood glucose after 10-15 minutes and repeat administration of dextrose until the hypoglycemia has resolved (i.e., repeat administration if blood glucose remains <70 mg/dL [<3.9 mmol/L]).​[1][3][106]

Plus – treat underlying cause and advice

Back
ACUTE
|
level 3 (severe) hypoglycemia or unconscious or unable to take glucose orally
|
with intravenous access
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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 antidiabetic treatment) to prevent future episodes of hypoglycemia and reduce complications.​​[1][4]​​​ See Prevention.

1st line – glucagon or dasiglucagon

Back
ACUTE
|
level 3 (severe) hypoglycemia or unconscious or unable to take glucose orally
|
without intravenous access
1st line – 

glucagon or dasiglucagon

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.

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.

Recheck the patient's blood glucose after 10-15 minutes and repeat administration of 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.

In practice, intravenous dextrose should be given once intravenous access is available if the patient is still hypoglycemic 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

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

Plus – treat underlying cause and advice

Back
ACUTE
|
level 3 (severe) hypoglycemia or unconscious or unable to take glucose orally
|
without intravenous access
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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 antidiabetic treatment) to prevent future episodes of hypoglycemia and reduce complications.​​[1][4]​​ See Prevention.

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

1st line – oral glucose

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycemia and conscious and able to take glucose orally
1st line – 

oral glucose

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. 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]​​​

Recheck the patient's blood glucose after 10-15 minutes and repeat administration of glucose until the hypoglycemia has resolved (i.e., repeat administration if blood glucose remains <70 mg/dL [<3.9 mmol/L]).​[1][3][106]​​​

Plus – treat underlying cause and advice

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycemia and conscious and able to take glucose orally
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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 antidiabetic treatment) to prevent future episodes of hypoglycemia and reduce complications.​​[1][4]​​​ See Prevention.

2nd line – glucagon or dasiglucagon

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycemia and conscious and able to take glucose orally
2nd line – 

glucagon or dasiglucagon

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 glucagon (or dasiglucagon) as an alternative to glucose if the patient is unwilling to take glucose orally.[3]

  • 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.

Recheck the patient's blood glucose after 10-15 minutes and repeat administration of glucagon (or dasiglucagon) if 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.

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

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

Plus – treat underlying cause and advice

Back
ACUTE
|
level 1 (alert value) or 2 (clinically significant) hypoglycemia and conscious and able to take glucose orally
Plus – 

treat underlying cause and advice

Treatment recommended for ALL patients in selected patient group

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 antidiabetic treatment) to prevent future episodes of hypoglycemia and reduce complications.​​[1][4]​​​ 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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