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Hypoglycemia

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hypoglycemia are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024), the United Kingdom Kidney Association (UKKA 2023), the American Heart Association (AHA/ASA 2022,2019), the Endocrine Society (ES 2022,2016,2013,2009), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the Dumping Syndrome Consensus Group (DS-CG 2020), the ...
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Diagnostic investigations

Initial evaluation, patients with diabetes: as per ADA 2024 guidelines, assess for a history of hypoglycemia at every clinical encounter in all patients at risk for hypoglycemia and evaluate as indicated.
B
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  • Initial evaluation (patients without diabetes)

  • Screening for anxiety

  • Screening for cognitive impairment

Medical management

Oral carbohydrates
As per ADA 2024 guidelines:
Administer glucose as the preferred treatment of conscious patients with glucose < 70 mg/dL (< 3.9 mmol/L), although any form of glucose-containing carbohydrate may be used. Repeat the treatment if hypoglycemia persists 15 minutes after initial administration.
B
Avoid using carbohydrate sources high in protein for the treatment or prevention of hypoglycemia in patients with T2DM, as ingested protein appears to increase insulin response without increasing plasma glucose concentrations.
D
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  • IV carbohydrates and glucagon

Specific circumstances

Neonatal patients: as per PES 2015 guidelines, consider evaluating neonates suspected to be at high risk of having a persistent hypoglycemia disorder when the infant is ≥ 48 hours of age so that the period of transitional glucose regulation has passed and persistent hypoglycemia may be excluded before discharge home.
B
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  • Pediatric patients (evaluation)

  • Pediatric patients (glycemic targets, T1DM)

  • Pediatric patients (glycemic targets, diabetes mellitus type 2)

  • Pediatric patients (glucose monitoring, T1DM)

  • Pediatric patients (glucose monitoring, diabetes mellitus type 2)

  • Pregnant patients

  • Elderly patients

  • Patients with CKD (considerations for pharmacotherapy)

  • Patients with CKD (continuous glucose monitoring)

  • Patients with CKD (elderly patients)

  • Patients with post-bariatric hypoglycemia (general principles)

  • Patients with post-bariatric hypoglycemia (postprandial hyperinsulinemic hypoglycemia)

  • Patients with post-bariatric hypoglycemia (late dumping syndrome)

  • Patients with acute stroke

  • Patients with hyperkalemia

  • Patients with status epilepticus

Preventative measures

General principles
As per ADA 2024 guidelines:
Take into consideration the patient's risk for hypoglycemia when selecting diabetes medications and glycemic goals.
E
Provide structured education for hypoglycemia prevention and treatment in all patients taking insulin
A
or at risk for hypoglycemia, with ongoing education for patients experiencing hypoglycemic events.
B
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  • Choice of insulin

  • Continuous glucose monitoring

  • Counseling on alcohol use

Follow-up and surveillance

Post-hypoglycemia care: as per DC 2018 guidelines, advise patients to have the usual meal or snack that is due at that time of the day, once the hypoglycemia has been reversed, to prevent repeated hypoglycemia. Advise having a snack (including 15 g carbohydrate and a protein source) if a meal is > 1 hour away.
B
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