Hypoglycemia in diabetes: An update on pathophysiology, treatment, and prevention

Table 1 Protocols for treating hypoglycemia

Steps	Procedure
	Adults who are conscious, orientated, and able to swallow
1	If the patient is receiving insulin (pump or IV infusion), stop it immediately
2	Give 15-20 g rapid-acting carbohydrate of the patient’s choice where possible. Examples include: 15-20 g chewable glucose tablets, 150-200 mL orange juice, or 3-4 heaped teaspoons of sugar dissolved in water
3	Repeat capillary blood glucose measurement 10-15 min later. If it is still less than 70 mg/dL, repeat the previous step up to 3 times
4	If the capillary blood glucose remains less than 70 mg/dL after 30-45 min or three cycles of treatment, consider IV 200 mL of 10% glucose over 15 min or administration of 1 mg of glucagon IM
5	Once blood glucose is above 70 mg/dL and the patient has recovered, it is recommended to give a long-acting carbohydrate. Examples: one slice of bread, a 200-300 mL glass of milk, or two biscuits
	Adults who are conscious but confused, unable to cooperate but able to swallow
1	If the patient is receiving insulin (pump or IV infusion), stop it immediately
2	If the patient is uncooperative but is able to swallow, give a 15g tube of glucose (e.g., Glucogel), squeezed into the mouth between the teeth and gums, or (if this is ineffective) glucagon 1mg IM
3	Repeat capillary blood glucose levels after 10-15 min. If it is still less than 70 mg/dL, repeat the previous step up to three times (glucagon injection should only be given once)
4	If the capillary blood glucose remains less than 70 mg/dL after 30-45 min (or three cycles of treatment), give IV 200 mL of 10% glucose over 15 min
5	Once blood glucose is above 70 mg/dL and the patient has recovered, giving a long-acting carbohydrate is recommended (as detailed above)
	Adults who are unconscious and/or having seizures
1	An urgent medical assessment is required. The following things should be checked and treated accordingly: Airway (administration of oxygen as appropriate), breathing, circulation (pulse), state of consciousness, blood glucose concentration, and body temperature
2	If the patient is receiving insulin (pump or IV infusion), stop it immediately
3	Request immediate assistance from medical staff
4	If IV access is available, give 100 mL of 20% glucose IV or 200 mL of 10% glucose over 15 min
5	If no immediate IV access is available, give 1mg glucagon IM. If no IV access is available initially, continue trying to obtain IV access as IM glucagon is less likely to be successful if required for a second time. If there is a need for prolonged treatment, IV administration of glucose is the treatment of choice
6	Capillary blood glucose test should be repeated after 10 min. If it is still less than 70 mg/dL repeat step 4 (or step 5 if IV access remains unavailable)
7	Once the blood glucose is greater than 70 mg/dL and the patient has recovered, give a long-acting carbohydrate (as previously detailed)

In an unconscious person with hypoglycemia, glucose may also be given as 20-50 mL of 50% glucose IV over 1-3 min in accordance with Diabetes Canada guidelines [33]. However, it is important to monitor the infusion, especially if given peripherally. The risk of extravasation during the administration of hypertonic glucose solution should be emphasized, as this may lead to significant tissue damage. It is important to note that glucagon may be less effective when administered repeatedly, in cases of sulfonylurea use, after alcohol consumption, and in patients with chronic liver disease. Individuals who received glucagon require a larger portion of complex carbohydrate (40 g) to replenish glycogen stores. Take into account that sometimes nausea appears after administration of glucagon. If hypoglycemia was secondary to sulfonylurea or long-acting insulin, the risk of hypoglycemia may persist 24-36 h following the last dose, especially in people with renal insufficiency.