- •It is important to prevent, recognize and treat hypoglycemic episodes secondary to the use of insulin or insulin secretagogues.
- •The goals of treatment for hypoglycemia are to detect and treat a low blood glucose (BG) level promptly by using an intervention that provides the fastest rise in BG to a safe level, to eliminate the risk of injury and to relieve symptoms quickly.
- •It is important to avoid overtreatment, since this can result in rebound hyperglycemia and weight gain.
Definition of Hypoglycemia
|Mild: Autonomic symptoms are present. The individual is able to self-treat.|
Moderate: Autonomic and neuroglycopenic symptoms are present. The individual is able to self-treat.
Severe: Individual requires assistance of another person.
Unconsciousness may occur. PG is typically <2.8 mmol/L.
Complications of Severe Hypoglycemia
- Jacobson A.M.
- Musen G.
- Ryan C.M.
- et al.
Long-term effect of diabetes and its treatment on cognitive function.
- de Galan B.E.
- Zoungas S.
- Chalmers J.
- et al.
Treatment of Hypoglycemia
Hypoglycemia and driving
- 1.Mild to moderate hypoglycemia should be treated by the oral ingestion of 15 g carbohydrate, preferably as glucose or sucrose tablets or solution. These are preferable to orange juice and glucose gels [Grade B, Level 2 (35)]. Patients should retest BG in 15 minutes and re-treat with another 15 g carbohydrate if the BG level remains <4.0 mmol/L [Grade D, Consensus]. Note: This does not apply to children. See Type 1 Diabetes in Children and Adolescents, p. S153, and Type 2 Diabetes in Children and Adolescents, p. S163, for treatment options in children.
- 2.Severe hypoglycemia in a conscious person should be treated by oral ingestion of 20 g carbohydrate, preferably as glucose tablets or equivalent. BG should be retested in 15 minutes and then re-treated with another 15 g glucose if the BG level remains <4.0 mmol/L [Grade D, Consensus].
- 3.Severe hypoglycemia in an unconscious individual
- a.With no IV access: 1 mg glucagon should be given subcutaneously or intramuscularly. Caregivers or support persons should call for emergency services and the episode should be discussed with the diabetes healthcare team as soon as possible [Grade D, Consensus].
- b.With IV access: 10–25 g (20–50 cc of D50W) of glucose should be given intravenously over 1–3 minutes [Grade D, Consensus].
- 4.For individuals at risk of severe hypoglycemia, support persons should be taught how to administer glucagon by injection [Grade D, Consensus].
- 5.Once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of the day to prevent repeated hypoglycemia. If a meal is >1 hour away, a snack (including 15 g carbohydrate and a protein source) should be consumed [Grade D, Consensus].
- 6.Patients receiving antihyperglycemic agents that may cause hypoglycemia should be counselled about strategies for prevention, recognition and treatment of hypoglycemia related to driving and be made aware of provincial driving regulations [Grade D, Consensus].
- Abbreviation:BG, blood glucose.
Other Relevant Guidelines
- Association of hypoglycemic symptoms with patients' rating of their health-related quality of life state: A cross sectional study.Health Qual Life Outcomes. 2010; 8: 86
- Fear of hypoglycaemia in adults with Type 1 diabetes.Diabet Med. 2010; 27: 1151-1158
- Beliefs about insulin as a predictor of fear of hypoglycaemia.Chronic Illn. 2009; 5: 250-256
- Fear of hypoglycaemia in parents of young children with type 1 diabetes: a systematic review.BMC Pediatr. 2010; 10: 50
- Type 1 diabetes among adolescents: reduced diabetes self-care caused by social fear and fear of hypoglycemia.Diabetes Educ. 2009; 35: 465-475
- Fear of hypoglycaemia in mothers and fathers of children with Type 1 diabetes is associated with poor glycaemic control and parental emotional distress: a population-based study.Diabet Med. 2010; 27: 72-78
- Symptoms of hypoglycaemia.in: Frier B.M. Fisher B.M. Hypoglycaemia and Diabetes: Clinical and Physiological Aspects. Edward Arnold, London, UK1993: 93-103
- Effects of intensive therapy and antecedent hypoglycemia on counterregulatory responses to hypoglycemia in type 2 diabetes.Diabetes. 2009; 58: 701-709
- Blunted counterregulatory hormone responses to hypoglycemia in young children and adolescents with well-controlled type 1 diabetes.Diabetes Care. 2009; 32: 1954-1959
- Effects of intensive diabetes therapy on neuropsychological function in adults in the Diabetes Control and Complications Trial.Ann Intern Med. 1996; 124: 379-388
- Mortality and treatment side-effects during long-term intensified conventional insulin treatment in the Stockholm Diabetes Intervention Study.Diabetes. 1994; 43: 313-317
- Long-term effect of diabetes and its treatment on cognitive function.N Engl J Med. 2007; 356 (Published erratum appears in N Engl J Med. 2009;361:1914): 1842-1852
- The effects of type1 diabetes on cognitive performance: a meta-analysis.Diabetes Care. 2005; 28: 726-735
- Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus.JAMA. 2009; 301: 1565-1572
- The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study.BMJ. 2010; 340: b4909
- Effects of acute insulin-induced hypoglycemia on indices of inflammation: putative mechanism for aggravating vascular disease in diabetes.Diabetes Care. 2010; 33: 1591-1597
- Effects of controlled hypoglycaemia on cardiac repolarisation in patients with type 1 diabetes.Diabetologia. 2008; 51: 426-435
- Continuous glucose monitoring reveals associations of glucose levels with QT interval length.Diabetes Technol Ther. 2010; 12: 283-286
- Adverse events and their association with treatment regimens in the Diabetes Control and Complications Trial.Diabetes Care. 1995; 18: 1415-1427
- Hypoglycemia in the Diabetes Control and Complications Trial.Diabetes. 1997; 46: 271-286
- Risk factors of severe hypoglycaemia in adult patients with type I diabetes: a prospective population based study.Diabetologia. 1998; 41: 1274-1282
- Epidemiology of severe hypoglycemia in the Diabetes Control and Complications Trial.Am J Med. 1991; 90: 450-459
- Hypoglycemia: incidence and clinical predictors in a large population-based sample of children and adolescents with IDDM.Diabetes Care. 1997; 20: 22-25
- Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: a meta-analysis.Diabet Med. 1997; 14: 919-928
- Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia.Diabetes Care. 1994; 17: 697-703
- Hypoglycemia unawareness in IDDM.Diabetes Care. 1994; 17: 1397-1403
- Effects of autonomic neuropathy on counterregulation and awareness of hypoglycemia in type 1 diabetic patients.Diabetes Care. 1998; 21: 1960-1966
- Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial.J Pediatr. 1994; 125: 177-188
- The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study.BMJ. 2010; 340: b5444
- Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial.Diabetologia. 2009; 52: 2328-2336
- Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: the Diabetes Study of Northern California (DISTANCE).J Gen Intern Med. 2010; 25 (Published erratum appears in J Gen Intern Med. 2010;25:1258): 962-968
- Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes.J Health Care Poor Underserved. 2010; 21: 1227-1233
- Determinants of severe hypoglycemia complicating type 2 diabetes: the Fremantle diabetes study.J Clin Endocrinol Metab. 2010; 95: 2240-2247
- Prevalence of impaired awareness of hypoglycaemia and frequency of hypoglycaemia in insulin-treated type 2 diabetes.Diabetes Res Clin Pract. 2010; 87: 64-68
- The search for an optimized treatment of hypoglycemia. Carbohydrates in tablets, solution, or gel for the correction of insulin reactions.Arch Intern Med. 1990; 150: 589-593
- Alanine and terbutaline in treatment of hypoglycemia in IDDM.Diabetes Care. 1993; 16: 1131-1136
- Treatment of insulin reactions in diabetics.JAMA. 1984; 252: 3378-3381
- Special problems.in: Skyler J.S. Medical Management of Type 1 Diabetes. 3rd ed. American Diabetes Association, Alexandria, VA1998: 134-143
- The role of dietary sugars in diabetes mellitus.Beta Release. 1991; 15: 117-123
- Bioactivity of instant glucose. Failure of absorption through oral mucosa.JAMA. 1978; 240: 1611-1612
- Glucobay® (acarbose) [product monograph]. Bayer Inc., Toronto, ON2007
- Hypoglycemia. Diabetes Care. 1994; 17: 734-755
- Glucagon [product monograph]. Eli Lilly Canada Inc., Toronto, ON2007
- GlucaGen® (glucagon) [product monograph]. Novo Nordisk, Bagsvaerd, Denmark2002
- Diabetes and fitness to drive: a systematic review of the evidence with a focus on older drivers.Canadian J Diabetes. 2010; 34: 233-242