Preventing and Managing Hypoglycemia in Patients with Diabetes
Full update November 2019
Hypoglycemia is a serious concern in patients with diabetes. Hypoglycemia can cause irreversible cognitive impairment, dementia, falls, vehicular accidents, other injuries, and death.1 The table below addresses common clinical questions about hypoglycemia in patients with diabetes. Educate patients with our patient handout, How To Handle Low Blood Sugar.
Abbreviations: ADA = American Diabetes Association; IM = intramuscular; SC = subcutaneous
Clinical Question |
Suggested Approach or Resource |
Which patients are at highest risk of hypoglycemiaa? |
Patients with Type 1 diabetes (highest risk)
Patients with type 2 diabetes using insulin or sulfonylurea (lower risk), especially with:
Certain medications may affect perception or response to hypoglycemia:7
|
What are the symptoms of hypoglycemia? |
Symptoms can be classified as autonomic (neurogenic) or neuroglycopenic.2
|
Do analog insulins pose a lower risk of hypoglycemia? |
See our chart, Insulin Analogs vs Human Insulin. |
What resources are available to help educate patients about hypoglycemia? |
From the American Diabetes Association:
From Diabetes Canada:
|
How can hypoglycemia be prevented? |
Patients should be educated to manage situations that put them at risk of hypoglycemia: fasting, delayed meals, alcohol use, exercise, or sleep.1 For example:
In at-risk patients, ask about hypoglycemia at each visit.1 Choose a preprandial glucose target that balances glycemic control and risk of hypoglycemia: 80 to 130 mg/dL (4.4 to 7.2 mmol/L) [Evidence level B-3].1,3 Re-think the treatment regimen if the patient experiences hypoglycemia unawareness or level 3 hypoglycemia.a,1 For insulin-treated patients with hypoglycemia unawareness, or an episode of level 2 hypoglycemia,a target glucose should be increased to avoid hypoglycemia for several weeks to three months to help restore awareness.1,2 Prescribers, the patient, and caregivers should monitor cognitive function.1 Consider continuous glucose monitoring for appropriate patients. Be watchful for medications that might cause hypoglycemia (e.g., quinolones, tramadol).15,16 |
What is the general approach to treatment of hypoglycemia? |
If the patient is conscious, give glucose 15 to 20 g (20 g if severea) if blood glucose <70 mg/dL (4 mmol/L).1,2 See footnote b for glucose source examples. Repeat glucose 15 g in 15 minutes if blood glucose still <70 mg/dL (4 mmol/L).1.2 If the patient is unconscious, or unwilling to cooperate with oral intake, give glucagon.1,2 If intravenous access is available, give 20 to 50 mL of D50W (i.e., 10 to 25 g of glucose) over one to three minutes.2
Once hypoglycemia is reversed, the patient should eat their usual meal, or snack if the usual mealtime is >1 hour away.2 The snack should consist of 15 g carbohydrate plus protein (e.g., seven crackers plus a piece of cheese, or a slice of bread plus two tablespoons of peanut butter).2,5 Patients taking acarbose (Precose [U.S.], Glucobay [Canada]) or miglitol (Glycet, Canada) must use glucose tablets, one cup of non-fat milk, or one tablespoon honey.2,13 |
Which patients should have a glucagon product on hand? |
All patients at risk of level 2 hypoglycemiaa should have unexpired glucagon or dasiglucagon (U.S. only) on hand (Note: dasiglucagon is NOT included in guideline recommendations, as it was FDA-approved approved after publication).1,22
|
How should glucagon products be stored? |
Baqsimi
GlucaGen Hypokit
Gvoke HypoPen or Gvoke PFS (U.S.)
Zegalogue (U.S.)
|
How do newer glucagon products compare to traditional glucagon injection? |
Ease of use
Cost
Efficacy
Tolerability
|
- SEVERITY OF HYPOGLYCEMIA
American Diabetes Association1 |
Diabetes Canada2 |
Level 1: glucose <70 mg/dL (4 mmol/L) but ≥54 mg/dL (3 mmol/L). Considered clinically important, even if asymptomatic. |
Mild: autonomic (neurogenic) symptoms present. Patient can self-treat. |
Level 2: glucose <54 mg/dL (3 mmol/L] |
Moderate: autonomic (neurogenic) and neuroglycopenic symptoms present, but patient can self-treat. |
Level 3: severe episode with impaired mental or physical function requiring assistance. Risk of seizures, unconsciousness, and death. |
Severe: patient requires assistance. Loss of consciousness may occur. Glucose usually <2.8 mmol/L (50 mg/dL). |
- Glucose sources (15 g):2,4,5,12,13,14
- glucose tablets (3 to 4 tablets)
- 1 heaping tablespoon (3 packets) of table sugar
- 5 sugar cubes
- Raisins (2 tablespoons)
- 1/2 cup of fruit juice or regular (non-diet) soft drink
- 6 Life Savers
- 1 tablespoon (15 mL) of honey, syrup, or corn syrup
- Cost is wholesale acquisition cost (WAC). Medication pricing by Elsevier, accessed May 2021.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]
Project Leader in preparation of this clinical resource (351108): Melanie Cupp, Pharm.D., BCPS; last modified May 2021.
References
- Standards of medical care in diabetes – 2019. Diabetes Care 2019;42(Suppl 1):S1-193.
- Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2018;42(Suppl 1):S1-S325.
- Wei N, Zheng H, Nathan DM. Empirically establishing blood glucose targets to achieve HbA1c goals. Diabetes Care 2014;37:1048-51.
- American Diabetes Association. Hypoglycemia (low blood sugar). https://www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/hypoglycemia. (Accessed September 1, 2019).
- Diabetes Canada. Hypoglycemia low blood sugar in adults. https://www.diabetes.ca/diabetescanadawebsite/media/managing-my-diabetes/tools%20and%20resources/hypoglycemia-low-blood-sugar-in-adults.pdf?ext=.pdf. (Accessed September 1, 2019).
- Anon. How to administer glucagon. Diabetes Forecast. September 2017. http://www.diabetesforecast.org/2017/sep-oct/how-to-administer-glucagon.html. (Accessed September 1, 2019).
- White JR. The contribution of medications to hypoglycemia unawareness. Diabetes Spectr 2007;20:77-80.
- Product information for GlucaGen Hypokit. NovoNordisk. Plainsboro, NJ 08536. July 2018.
- Product information for Baqsimi. Eli Lilly and Company. Indianapolis, IN 46285. July 2019.
- Yale JF, Dulude H, Egeth M, et al. Faster use and fewer failures with needle-free nasal glucagon versus injectable glucagon in severe hypoglycemia rescue: a simulation study. Diabetes Technol Ther 2017;19:423-32.
- Product monograph for GlucaGen HypoKit. Mississauga, ON L4W 5L6. June 2016.
- NIDDK. Low blood glucose (hypoglycemia). https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-hypoglycemia. (Accessed September 2, 2019).
- Anon. Hypoglycemia? Low blood glucose? Low blood sugar? Clin Diabetes 2012;30:38.
- McCall AL. Insulin therapy and hypoglycemia. Endocrinol Metab Clin North Am 2012;41:57-87.
- Murad MH, Coto-Yglesias F, Wang AT, et al. Clinical review: drug-induced hypoglycemia: a systematic review. J Clin Endocrinol Metab 2009;94:741-5.
- Clinical Resource, Tramadol and Hypoglycemia. Pharmacist’s Letter/Prescriber’s Letter.February 2015.
- Product information for Gvoke. Xeris Pharmaceuticals. Chicago, IL 60601. September 2019.
- Valentine V, Newswanger B, Prestrelski S, et al. Human factors usability and validation studies of a glucagon autoinjector in a simulated severe hypoglycemia rescue situation. Diabetes Technol Ther 2019;21:522-30.
- Product monograph for Baqsimi. Eli Lilly Canada. Toronto, ON M5X 1B1. September 2019.
- Xeris Pharmaceuticals. Gvoke now approved! September 13, 2019. https://www.gvokeglucagon.com/pdf/now_approved_gvoke_webcast.pdf. (Accessed October 3, 2019).
- Eli Lilly. Medical answers. Baqsimi (glucagon) nasal powder). August 20, 2019. https://www.lillymedical.com/US/EN/answers/nasal-glucagon-glucagon-synthetic-shelf-life-and-stability/43823. (Accessed October 3, 2019).
- Product information for Zegalogue. Zealand Pharma A/S. Søborg, Denmark. March 2021.
Cite this document as follows: Clinical Resource, Preventing and Managing Hypoglycemia in Patients with Diabetes. Pharmacist’s Letter/Prescriber’s Letter. November 2019.